Journal of Dentistry 45 (2016) 1–6

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Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden

Predictive factors on the efficacy and risk/intensity of tooth sensitivity

of dental bleaching: A multi regression and logistic analysis
Márcia Rezende, Alessandro D. Loguercio, Stella Kossatz, Alessandra Reis*
School of Dentistry, State University of Ponta Grossa, Ponta Grossa, Paraná,Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: The aim of this study was to identify predictor factors associated with the whitening outcome
Received 1 June 2015 and risk and intensity of bleaching-induced tooth sensitivity from pooled data of 11 clinical trials of
Received in revised form 11 November 2015 dental bleaching performed by the same research group.
Accepted 17 November 2015
Methods: The individual patient data of several published and ongoing studies about dental bleaching
was collected and retrospectively analyzed. At the patient-level, independent variables (bleaching
Keywords: techniques [at-home and in-office protocols], sex, age and baseline tooth color in shade guide unit [SGU])
Dental bleaching
as well as dependent variables (color change in shade guide units (DSGU), color change in the CIEL*a*b*
Predictive factors
Dentin sensitivity
system (DE), risk and intensity of TS in a visual analog scale) were collected. Multivariable linear
Color change regression and multivariable logistic regression models were carried out using backward elimination
Hydrogen peroxide whenever the p-values were higher than 0.05.
Results: A significant relationship between baseline color and age on color change estimates was detected
(p < 0.001). Every increase of one SGU in the baseline color resulted in an increase of approximate 0.66 in
the final DSGU and 2.48 for the DE. For every increase of one year in the participant’s age we observed a
decrease of the whitening degree of 0.07 for the final DSGU and 0.69 for the DE. The bleaching technique
was shown to be a significant predictor of DSGU (p < 0.001) but not of DE. In regard to TS, baseline color
and bleaching technique are significant predictors (p < 0.001). The risk of TS for at-home bleaching was
51% (95% CI 41.4–60.6) and for the in-office 62.9% (95% CI 56.9–67.3).
Conclusions: Younger patients with darker teeth reach a higher degree of whitening. Patient with darker
teeth and submitted to at-home bleaching presents lower risk and intensity of TS.
Clinical significance: The baseline color of the teeth and the patient’s age is directly related to the
effectiveness of dental bleaching and TS.
ã 2015 Elsevier Ltd. All rights reserved.

1. Introduction Several studies have already reported the effectiveness of at-

The increase in patient awareness of the ability to improve their
smiles has been responsible for the boom in esthetic dentistry in
recent years. Among all therapies for improving the patient’s smile,
dental bleaching has been widely employed by dental practi-
tioners, as it is a very conservative, simple, low-cost and safe
procedure. A survey conducted in the United Kingdom and
published in 2008 revealed that more than 80% of general dental
practitioners perform dental bleaching in their offices [1].
* Corresponding author at: Universidade Estadual de Ponta Grossa, Departa-
mento de Odontologia, Rua Carlos Cavalcanti, 4748, Bloco M, Sala 64, Uvaranas,
Ponta Grossa, Paraná 84030-900, Brazil.
E-mail addresses: mfssiqueira@uol.com.br (M. Rezende),
aloguercio@hotmail.com (A.D. Loguercio), stellakp@hotmail.com (S. Kossatz),
reis_ale@hotmail.com (A. Reis).
home and in-office dental bleaching [2–7]. This means that all
patients may have their teeth whitened to some degree, although
the individual whitening response is affected by multiple factors
[8], including those associated with product formulation and
usage. The higher the peroxide concentration and the longer the
contact time, the faster the whitening [9–11].
Although this explains the differences observed between
patients when subjected to different bleaching therapies, it does
not justify the individual variations observed after the application
of the same bleaching protocol. For instance, most clinical trials
[12–15] report a mean change of 3 shade guide units after one in-
office bleaching session of 45 min with 35% hydrogen peroxide;
however, this protocol may not produce any noticeable color
change in some patients, which may impact patients’ and
professionals’ expectations and influence patients’ confidence
in professionals.

http://dx.doi.org/10.1016/j.jdent.2015.11.003
0300-5712/ ã 2015 Elsevier Ltd. All rights reserved.
2 M. Rezende et al. / Journal of Dentistry 45 (2016) 1–6

Table 1
Characteristics of the studies from each raw data were collected (n = 426 patients).

Study Groups Study Material Bleaching Study sample Participant’s age Baseline Method Method of
design (brand) protocol [sample – mean
SD Color of tooth sensitivity
collected for [range] color assessment
this study] assessment
Rezende et al. G1: At-home without Parallel 16% CPd 3 h/daily for 3 40 [40] 23.1
5.3 A2 or SGU Vita NRS 0–4
[28] coffee exposure weeks [18–40] darker Classicale VAS 0–10
f
G2: At-home with Spectrophotomer
coffee exposure
Rezende et al. G1: Parallel 35% HPg 2 sessions, 63 [60]a 22.7
4.1 A1 or SGU Vita NRS 0–4
[17] Dexamethasone + in- 1 week-interval [18–33] darker Classicale VAS 0–10
Office 45 min Spectrophotomerf
G2: Placebo + in- (3  15 min) each SGU Vita
Office Bleachedguideh
Rezende et al. G1: In-Office + at- Parallel G1: 35% 2 sessions, 30 [14]b 26.1
8.6 A2 or SGU Vita NRS 0–4
[30] homea HPi + 6% HPj 1 week-interval [18–42] darker Classicale
G2: In-Office G2: 35% HPi 45 min
(3  15 min) each
Reis et al. [27] G1: In-Office Parallel G1: 35% HP 2 sessions, 60 [45]a 27
8.3 C2 or SGU Vita NRS 0–4
k
G2: In-Office Blue 1 week-interval [18–49] darker Classicale
G2: 20% HP A single 40–
l
Blue 50 min
application
de Geus et al. G1: At-home in Parallel 10% CPm 3 h/daily for 120 [60]c 25.2
6.6 A2 or SGU Vita NRS 0–4
[23] smokers 3 weeks [18–46] darker Classicale VAS 0–10
G2: At-home in non- Spectrophotomerf
smokers
Bonafé et al. G1: In-office in sound Parallel G1 and G2: 2 sessions, 30 [30] 24.8
4.5 A2 or SGU Vita NRS 0–4
[15] teeth 35% HPg 1 week-interval [18–35] darker Classicale
G2: In-office in 45 min Spectrophotomerf
restored teeth (3  15 min) each
Bonafé et al. G1: placebo + in-office Parallel G1 and G2: 2 sessions, 30 [30] 24.8
4.2 A2 or SGU Vita NRS 0–4
[29] G2: desensitizing + in- 35% HPg 1 week-interval [18–35] darker Classicale
f
office 45 min Spectrophotomer
(3  15 min) each
Mena-Serrano G1: In-office 20% HP Parallel G1 and G2: 2 sessions, 78 [78] 22.5
3.8 A3 or SGU Vita NRS 0–4
et al. [31] G2: In-office 20% 20% HPo 1 week-interval [18–33] darker Classicale VAS 0–10
HP + LED/Lasern G3 and G4: 45 min Spectrophotomer
G3: In-office 35% HP 35% HPg (3  15 min) each
G4: In-office 35%
HP + LED/Lasern
de Paula et al. G1: Ascorbic acid + in- Parallel G1 and G2: 2 sessions, 39 [15]a 26.8
8.2 C2 or SGU Vita NRS 0–4
[24] Office 35% HPg 1 week-interval [18–45] darker Classicale VAS 0–10
G2: Placebo + in- 45 min Spectrophotomerf
Office (3  15 min) each
de Paula et al. G1: Etoricoxib + in- Parallel 35% HPg 2 sessions, 30 [30] 25.5
6.4 C2 or SGU Vita NRS 0–4
[25] Office 1 week-interval [18–42] darker Classicale NRS 0–100
f
G2: Placebo + in- 45 min Spectrophotomer VAS 0–10
Office (3  15 min) each
Paula et al. G1: In-Office + Parallel 35% HPg 2 sessions, 30 [24]a 29.6
8.3 C2 or SGU Vita NRS 0–4
[26] Ibuprofen 1 week-interval [18–56] darker Classicale VAS 0–10
G2: In-Office + 45 min Spectrophotomerf
Placebo (3  15 min) each

CP: Carbamide peroxide; HP: hydrogen peroxide; SGU: shade guide units; NRS: numeric rating scale; VAS: visual analog scale; LED: Light-emitting diode.
a
Less data than the original study was used due to missing information.
b
Data from this group (combined at-home + in-office bleaching) was not added in this regression analysis as this could not be compared to the other groups.
c
Only data from the Brazil center was added to this analysis to standardize the same population in all studies.
d
Whiteness Perfect 16%, FGM, Joinville, Santa Catarina, Brazil.
e
Vitapan Classical, Vita Zahnfabrik,Bad Säckingen, Germany.
f
Vita Easyshade, Vita Zahnfabrik,Bad Säckingen, Germany.
g
Whiteness HP Maxx 35%, FGM, Joinville, Santa Catarina, Brazil.
h
Vita Bleachedguide 3D-Master, Vita Zahnfabrik, Bad Säckingen, Germany.
i
Mix One Supreme 35%, FGM, Joinville, Santa Catarina, Brazil.
j
Mix Day 6%, Villevie, Joinville, Santa Catarina, Brazil.
k
Whiteness HP Blue 35%, FGM, Joinville, Santa Catarina, Brazil.
l
Whiteness HP Blue 20%, FGM, Joinville, Santa Catarina, Brazil.
m
Whiteness Perfect 10%, FGM, Joinville, Santa Catarina, Brazil.
n
Whitening Lase Light Plus, DMC Odontológica, São Carlos, São Paulo, Brazil.
o
The 20% HP gel was produced exclusively for this study by FGM company, keeping the same characteristics of the Whiteness HP Maxx gelb.

Understanding of patient-related variables that can affect
dental bleaching, such as age, gender and baseline tooth color,
as well as those that can predispose bleaching-induced tooth
sensitivity can help predict patient response to treatment and
allow clinicians to determine the best treatment modality for each
individual. Additionally, clinicians may set appropriate expect-
ations to avoid disappointments and frustrations during treat-
ment.
As the individual clinical trials published in the literature do not
have a high sample size to allow for such predictions, pooling data
 M. Rezende et al. / Journal of Dentistry 45 (2016) 1–6
from different clinical trials from the same research group, a
procedure already done in previous studies [8,16], is a good
research tool to increase the power of a study to understand
important questions related to bleaching.
Therefore, the aim of this study was to identify predictor factors
associated with the whitening outcome and risk and intensity of
bleaching-induced tooth sensitivity from pooled data of 11 clinical
trials of dental bleaching performed by the same research group.
2. Material and methods
The individual patient data of several published and ongoing
studies (Table 1) about dental bleaching were collected and
retrospectively analyzed. All studies were developed by the same
research group under the coordination of experienced researchers
(A.R., S.K. and A.D.L.) at the State University of Ponta Grossa
(Paraná, Brazil) between 2011 and 2014.
The eligibility criteria of these studies were quite similar and
involved participants from both genders with a minimum age of
18 years. All studies excluded volunteers presenting severe internal
tooth discoloration (tetracycline stains, fluorosis and pulpless
teeth), bruxism habits or any other pathology that could cause
sensitivity (such as recession and dentin exposure). Pregnant/
lactating women and volunteers who had undergone tooth-
whitening procedures were also not eligible for inclusion in these
studies (Table 1).
All eleven studies included in this article were randomized
clinical trials with a parallel design (Table 1). Adherence to at-
home bleaching was controlled by given the participants the
amount of gel required for one week bleaching so that excesses in
the product usage could be detected and amended. Well-trained
and calibrated examiners performed the bleaching procedures (at
home and in office) and data collection. The data collection was
executed with standard and very similar protocols, which enabled
data from different studies to be compared. The color evaluation
method and the assessment of bleaching-induced tooth sensitivity
in the primary studies were done similarly as described below.
2.1. Color evaluation
Color evaluation in the primary clinical trials was performed
before and after bleaching (1 week or 30 days post bleaching) using
a value-oriented shade guide unit (Vita Lumin, Vita Zahnfabrik, Bad
Säckingen, Germany) and/or spectrophotometer (Easyshade,
Vident, Brea, CA). As only one study employed the Vita
Bleachedguide 3D-Master (Vita Zahnfabrik, Bad Säckingen,
Germany), it was not included in the present study [17].
The 16 shade guide tabs were arranged from highest (B1) to
lowest (C4) value, and each tab was given an ordered number (from
1 to 16). The authors from the primary studies calculated color
changes from the start of the active phase to the post-bleaching
period in the number of shade guide units (DSGU) that occurred
toward the lighter end of the value-oriented list of shade tabs.
For the objective evaluation, a preliminary impression of the
maxillary arch was made using dense silicone. A window was
created on the labial surface of the molded silicone guide for the
central incisor to be evaluated. One operator took all the
measurements in all 30 patients, using Vita Easyshade (Easyshade,
Vident, Brea, CA) before and after the bleaching therapy. The shade
was determined using the parameters L*, (a*), and (b*), in which L*
represents the value from 0 (black) to 100 (white) and a* and b*
represent the shade, where a* is the measurement along the red–
green axis and b* is the measurement along the yellow–blue axis.
The color comparison before and after treatment was given by the
3
difference between the two colors (DE), which was calculated
using the formula DE ¼ ½ðDLÞ2 þ ðDaÞ2 þ ðDbÞ2 1=2
2.2. Tooth sensitivity
Subjects were asked to record whether they experienced tooth
sensitivity (TS) during and after the treatment. Each patient
recorded several scores during treatment. Participants submitted
to in-office bleaching recorded the pain immediately after
bleaching, up to 24 h post-bleaching and from 24 to 48 h post
bleaching. Participants submitted to the at-home protocol
recorded daily the VAS pain score. For data analysis a summary
value from these scores were taken per patient. In this case we
opted to take the highest VAS score recorded by the patient. The
values were arranged into two categories: percentage of patients
who reported TS at least once during treatment (absolute risk of
TS) and overall TS intensity. Although more than one pain scale
was used in the primary studies (a 5-point verbal rating scale
[0 = none, 1 = mild, 2 = moderate, 3 = considerable, and 4 = severe],
a 0–100 numerical rating scale and a visual analogue scale [VAS]
using a 10 cm horizontal line with words “no pain” at one end and
“worst pain” at the opposite), we collected responses only on the
VAS scale.
2.3. Data collection and statistical analysis
At the patient level, the following independent variables were
collected: study ID, bleaching technique (at home or in office);
concentration of active hydrogen peroxide in the bleaching gel, sex,
age and baseline tooth color in SGU (Table 1). The dependent
variables DSGU and DE (baseline vs. one month post bleaching),
risk and intensity of TS on the VAS scale were also collected.
For the continuous dependent variables (DSGU, DE and TS
intensity), three multivariable linear regression models were
carried out using the statistical package SigmaPlot for Windows
(version 11.0, Systat Software, GmbH, Germany) to determine the
impact of the aforementioned independent variables on color
change. The multivariable analysis started with potential pre-
dictors (a) bleaching technique, (b) sex, (c) age and (d) baseline
color. A multivariable logistic regression was conducted for the
absolute risk of TS, using the same independent variables
described in the multiple linear regression models. Backward
elimination was used whenever the p-values were higher than
0.05.
3. Results
Table 1 reports the characteristics of all included studies. A total
of 426 participants were submitted to bleaching in the 11 included
studies (Table 1). All studies used the parallel clinical trial design.
The mean ages of the participants included in these primary
studies were very similar. The sample sizes varied from 30 to
120 participants. The most variable aspect in these studies was the
baseline color for participant inclusions. While some studies
included participants with lighter shades, such as A1 and A2, other
studies required participants to have incisors shade C2 or darker.
3.1. Color change
The results from the multivariable regression analysis for color
change can be seen in Table 2. The multivariable regression
analysis identified a significant relationship between baseline
color and age in relation to color change estimates (Table 2). After
adjustment for the other variables, every increase of one SGU in the
baseline color resulted in an increase of approximate 0.66 in the
4 M. Rezende et al. / Journal of Dentistry 45 (2016) 1–6

final DSGU and 2.48 for the DE, meaning that the darker the
baseline tooth color, the higher the degree of whitening. In an
opposite trend, for every increase of one year in the participant’s
age we observed a 0.07 decrease in the degree of whitening for the
final DSGU and a 0.69 decrease for the DE, suggesting that the
degree of whitening is negatively affected by the participant’s age.
The bleaching technique was shown to be a significant predictor
of DSGU (p < 0.001) but not of DE, probably because of the high
variability of the DE data (Table 3). In contrast, gender had no
significant impact in the prediction of the DSGU, while it was
significant for the DE values (p = 0.007). The DE for males was 4.78
lower than the DE for females (Table 2).
Approximately 57% of the variability of the DSGU values was
explained by the combination of the independent factors of
baseline color, age and bleaching technique. In regard to the DE,
23% of the data variation was explained by the independent factors
baseline color, age and gender (R2, Table 2).
3.2. Risk of tooth sensitivity (TS)
The results of the multivariable logistic regression are
presented in Table 3. The data revealed that baseline color and
bleaching technique are significant predictors of the risk of TS
(Table 3; p < 0.001). After adjustment for other variables, every
one-SGU increase in baseline color reduces the odds of TS by 17%.
The odds ratio of 2.20 for the bleaching technique indicates that TS
is 120% more likely to result from in-office bleaching than at-home
bleaching.
The descriptive data for the tooth sensitivity can be seen
in Table 4. For at-home bleaching, the risk of TS was 51% (95%
CI 41.4–60.6), and for in-office bleaching the risk was 62.9% (95%
CI 56.9–67.3) (Table 4).
3.3. Intensity of tooth sensitivity
The results from the multivariable regression analysis for the
intensity of TS can be seen in Table 5. A significant relationship
between baseline color and bleaching technique was observed for
the overall intensity of TS (Table 5). After adjustment for the other
variables, every increase of one SGU in the baseline color resulted
in a decrease of 0.13 in the intensity of TS. The intensity of TS
resulting from the in-office bleaching technique was 2.5 SGU units
higher than for the at-home technique. The overall mean of TS
intensity was 0.5
0.9 for at-home bleaching and 2.8
2.9 for in-
office bleaching (Table 4).
4. Discussion
Individual randomized clinical trials are usually not powered
enough to answer important clinical questions, such as the effects
Table 3
Coefficient, standard error (SE), odds ratios (OR), p-values and 95% confidence
intervals (CI) of the multivariable logistic regression analysis.a
Independent variables Coefficientb SE ORc p-value 95% CI
Baseline color (SGU) 0.18 0.66 0.83 <0.001 0.77–0.89
Bleaching technique 0.83 0.25 2.20 <0.001 1.36–3.58
a
Number of observations: 413; likelihood ratio test statistics p < 0.001.
b
The coefficient in this table gives the chance in the log odds of the outcome for a
one-unit increase in the predictor variable.
c
Odds ratio (OR) is defined as the ratio of the odds of an event occurring in one
group to the odds of it occurring in another group. Odds are defined as the ratio of
the probability of an ‘event’ and the probability of a ‘non-event’.
of predictors on the final outcome of any treatment, mainly
because these individual randomized clinical trials have a small
number of participants. Limitations such as funding, available
patients, access to testing and follow-up resources, and logistical
limitations often inherently preclude adequately powered mega-
trials from answering many investigative questions. Hence,
methods to properly combine studies to obtain more precise
results have understandable utility and appeal. Pooling data from
various trials enhances the power.
Pooling data from clinical trials can be done after running a
formal systematic review of the literature and asking authors to
provide their original data. During a systematic review of the
literature on this topic (unpublished data, CRD 42015015564) we
observed a high heterogeneity among studies in many issues, such
as type of materials, concentration of the products and significant
variations in the at-home and in-office bleaching protocols.
For instance, in the present study, in-office bleaching was
performed mostly with 35% hydrogen peroxide in two clinical
sessions of 45 min each. The use of a single bleaching session
[18–20] or even shorter application times of 10–20 min [2,19] was
reported in many clinical studies of bleaching. Such degree of
variation was also detected for at-home bleaching. In the studies
from the author’s group, 10 or 16% carbamide peroxide were used
for 3 h daily during 3 weeks. In studies published in the literature
the daily usage time ranged from 2 h [21] to 10 h [3,7,22] during 6
days [20], 14 days [7,18,19] and 21–28 days [3,6,21].
This variation in the literature studies explain why we opted to
only use the data from the author’s research group, which used a
similar protocol with few variations in concentrations of the
products for the bleaching techniques. Apart from that, we had
most of the original and raw data having the patients, which made
the analysis also convenient. Patients and not studies were the unit
of analysis, which increased the power of the study to find
important but small significant effects.
Additionally, all of the studies included in this regression
analysis were sampled from the same source of population and
assessed bleaching outcome and tooth sensitivity using very

Table 2
Parameter estimates from multivariable linear regression models for DSGU and DE.

Independent variables DSGU (R2 = 56.6%)a DE (R2 = 23.4%)b

Coefficientc Standard error p-value Coefficient Standard error p-value
Intercept 2.9 0.55 <0.001 18.64 4.52 0.002
Baseline color (SGU) 0.66 0.02 <0.001 2.48 0.27 <0.001
Age (yrs) 0.07 0.01 <0.001 0.69 0.14 <0.001
Genderd – – – 4.80 1.74 0.007
Bleaching techniqued 0.74 0.20 <0.001 – – –
a
Number of observations = 414; Standard Error of the estimate = 1.73; ANOVA p < 0.001; R2 (coefficient of determination) is a statistical measure of how close the data are to
the fitted regression line.
b
Number of observations = 351; Standard Error of the estimate = 16.14; ANOVA p < 0.001.
c
Coefficient in this table means that for every additional increase in the predictor variable, an increase of the coefficient size is expected to occur for the outcome variable.
d
Females and in-office bleaching have a better whitening response.
 M. Rezende et al. / Journal of Dentistry 45 (2016) 1–6
Table 4
Descriptive statistics of the color change (DSGU and DE), risk and intensity of tooth sensitivity [number of observations] by the independent factor bleaching technique.
At-home
DSGU (mean
SD)a 5.0
2.0 [100]
DE (mean
SD) 9.9
3.5 [100]
Risk of TS (%, 95% CI) 51 (41.4–60.6) [100]
TS intensity (mean
SD) 0.5
0.9 [100]
a
SD: standard deviation; CI: confidence interval; TS: tooth sensitivity.
similar instruments because they were conducted by the same
research team. Therefore, we assumed that heterogeneity was not
an issue and each study received the same weight. The pooled data
from these 11 studies [15,17,23–31] revealed that regardless of the
bleaching technique employed, baseline tooth color was shown to
have a significant effect on overall whitening efficacy; the darker
the teeth, the higher the degree of whitening. Gerlach and Zhou [8]
also reached a similar conclusion when using low-concentrated
whitening strips for bleaching.
4.1. Predictors of the whitening efficacy
The findings of an earlier study provided valuable insight into
the variability of bleaching efficacy among people. After several in
vitro experiments, a recent study found that hydrogen peroxide
whitens teeth by oxidizing their transparent organic matrix into an
opaque whiter material [32], showing that tooth bleaching by
hydrogen peroxides is controlled by the organic content of the
teeth. Therefore, the contrasted variability in organic content of
teeth among people [33] could be one of the reasons behind the
wide variation in the results obtained among individuals submit-
ted to dental bleaching.
As tooth color is determined mainly by the color of dentin [34],
which is an organic-rich substrate, one may assume that the better
bleaching efficacy in patients with yellower teeth reflects a likely
increased organic content and increased availability of organic
substrate for the oxidizing action of the hydrogen peroxide. In an
opposite trend, age was negatively correlated with the whitening
effect, meaning that older patients do not respond to the bleaching
procedure as well as the youngest patients, which may be
attributed to the physiological changes that occur in dental tissues
over time. It is known that the organic component of permanent
teeth reduces with age as a result of ongoing remineralization and
continuous deposition of secondary dentin in teeth as they
function in the oral environment [35,36]. The increase in dentin
thickness and decrease in the diameter of the dentinal tubules with
age due to thickening of the peritubular dentine and occlusion of
the dentinal tubules by mineral deposition are responsible for the
yellowing of teeth with age [37,38].
Additionally, it was already reported that enamel hydroxyapa-
tite crystals in permanent teeth increase with age [39], which may
reduce their organic content and diminish the permeability of
enamel to hydrogen peroxide [40,41]. In this way, hydrogen
peroxide might be obstructed from reaching the organic content of
the dental structure, which is protected in aged teeth by their
Table 5
Parameter estimates from multivariable linear regression models for the intensity
of tooth sensitivity (visual analogue scale).a
Independent variables Intensity of tooth sensitivity (R2 = 16.3%)
Coefficient Standard error
Intercept 1.14 0.57
Baseline color (SGU) 0.13 0.04
Bleaching techniqueb 2.50 0.30
a
Number of observations = 362; S = 2.53; ANOVA p < 0.001.
b
In-office bleaching has a higher tooth sensitivity intensity.
5
In-office Overall
5.3
2.8 [326] 5.2
2.6 [426]
15.9
21.6 [255] 14.2
18.6 [355]
62.9 (56.9–67.3) [323] 59.6 (54.8–64.1) [423]
2.8
2.9 [266] 2.2
2.7 [366]
higher mineral content. In summary, the age-related decrease in
protein content might be one of the reasons behind the lower
bleaching efficacy in teeth of elder individuals in this present study
and in an earlier one that evaluated low-concentrated whitening
strips for bleaching [8].
We also observed in the present study that in-office bleaching
was statistically efficient than at-home bleaching in terms of DSGU,
although this difference did not reach one SGU (Table 3). This means
that this statistically significant difference is not a clinically
important difference. Additionally, this finding should be interpreted
cautiously because the baseline color of patients included in the at-
home bleaching studies was lighter (A2) than the baseline color of
participants included in the in-office protocols (usually C2 or darker)
(Table 1). Perhaps, the lower whitening magnitude of the at-home
protocols might reflect much more the effect of baseline color than
the protocol per se. The majority of clinical studies that compared at-
home bleaching with in-office bleaching of teeth with the same
baseline color showed similar results for these two therapies [2–7].
Gender was found to be statistically associated with DE, with
women having a better whitening response for both bleaching
techniques. The reason for such association was not clear for the
authors and requires further investigations with basic methodolo-
gies.
4.2. Predictors of the risk and intensity of tooth sensitivity
Contrary to previous expectations, the age of the patients was not
related to the risk and intensity of tooth sensitivity, meaning that
tooth sensitivity did not decrease with age. This expectation was
based on the fact that as older patients have a thicker dentin structure
than younger patients, hydrogen peroxide needs to travel longer to
reach the pulp tissue in older teeth, reducing the amount of hydrogen
peroxide that reaches the pulp and the consequent damage.
This lack of correlation between age and bleaching-induced
tooth sensitivity was observed in another clinical study. The
authors reported that teeth with reduced thickness of dentin are
not more susceptible to bleaching-induced tooth sensitivity than
those with higher dental volume [42]. However, one cannot rule
out the fact that the mean ages of participants included in these 11
clinical trials [15,17,23–31] did not exceed 30 years in any of the
studies. This means that the effect of age on dental bleaching
should be investigated more deeply in future clinical trials.
Baseline color can predict tooth sensitivity. In other words, the
darker the teeth, the lower the intensity and risk of tooth sensitivity.
Darker teeth probably have higher organic content to retain the
hydrogen peroxide in the enamel and dentin substrates, allowing
less surplus hydrogen peroxide to travel to the pulp tissue. In these
circumstances, it is possible that less hydrogen peroxide comes in
contact with the pulp tissue, which generates lower tooth sensitivity.
This, however, is a hypothesis yet not supported by basic research.
p-value Future studies should also investigate this association.
0.04 At-home bleaching was associated with reduced risk and
0.002 intensity of tooth sensitivity compared to in-office bleaching,
<0.001 which was not a surprising finding. This difference may be directly
correlated with the concentrations of hydrogen peroxide used in
these two different protocols. A recent in vitro study demonstrated
6 M. Rezende et al. / Journal of Dentistry 45 (2016) 1–6
that the higher the concentration of bleaching agent, the higher the
aggression to the pulp cells [43,44].
Finally, we should mention the limitations of this study. The data
was collected from the source population, which prevents us from
generalizing these findings to all populations. Although randomiza-
tion in the original articles was performed for the studied treatments,
the variables assessed as predictors in the present study were not.
This means that the associations herein observed are merely
observational and suffers from the limitations of cross-sectional
study types. Cause and effect cannot be determined whenever data
come from cross-sectional studies. The results of this study are of
potential value in evaluating clinical risk ahead of treatment so that
litigation from unsuccessful whitening procedures is reduced;
however further research authors should be encouraged to perform
this type of analysis on their raw data to increase the body of evidence
in this field.
5. Conclusion
Younger patients and patients with darker teeth have a better
whitening response. Patients with darker teeth and those
submitted to at-home bleaching present lower risk and intensity
of tooth sensitivity.
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