Received: 14 November 2019 Revised: 5 June 2020
DOI: 10.1111/jerd.12617
RESEARCH ARTICLE
Over-the-counter bleaching agents can help with tooth
whitening maintenance
Olívia Santana Jorge Undergraduate Student |
Carolina Noronha Ferraz de Arruda DDS, MSc, PhD
Rafaella Tonani Torrieri BAcc, MSc | Rocio Geng Vivanco DDS, MSc Student
Fernanda de Carvalho Panzeri Pires-de-Souza DDS, MSc, PhD
Department of Dental Materials and
Prosthodontics, Ribeir~ao Preto School of
Dentistry, University of S~ao Paulo, Ribeir~ao
Preto, S~ao Paulo, Brazil
Correspondence
Fernanda de Carvalho Panzeri Pires-de-Souza,
Department of Dental Materials and
Prosthodontics, Ribeir~ao Preto School of
Dentistry, University of S~ao Paulo (FORP-
USP), Av. Do Café, s/n
, Bairro Monte Alegre,
CEP 14040-904 Ribeir~ao Preto – S~ ao Paulo.
Brazil.
Email: ferpanzeri@usp.br
Funding information
Sao Paulo Research Foundation (FAPESP),
Brazil, Grant/Award Number: 2017/09295-4
J Esthet Restor Dent. 2020;1–7.
Accepted: 10 June 2020
|
|
Abstract
Objective: This study evaluated the influence of over-the-counter agents on the
maintenance of color and microhardness of the enamel after home bleaching
protocol.
Materials and methods: Specimens of bovine teeth (6 × 6 × 2 mm) were prepared,
and color (Easyshade, VITA) and microhardness (HMV-2, Shimadzu) readings were
performed. All the specimens were bleached using 22% carbamide peroxide (22%CP),
except for the control group, and then separated into seven groups (n = 10) according
to the interaction of toothpaste (whitening, conventional, and whitening with perox-
ide) and mouth rinse (whitening and conventional). The study simulated 1 year of
toothbrushing (Pepsodent, MAVTEC) and mouth rinse by immersion. After that, final
color and microhardness measurements were performed. Data were analyzed by
one-way ANOVA, Tukey's test (P < .05).
Results: The group submitted to 22%CP + whitening toothpaste + whitening mouth
rinse showed higher color maintenance (P < .05) than the control group. The percep-
tion of whitening of teeth (ΔWID) was higher than the color change (ΔE00). There
was a decrease in microhardness after treatment with 22%CP + conventional
toothpaste + whitening mouth rinse.
Conclusions: Over-the-counter products can help with the maintenance of tooth
whitening after bleaching with carbamide peroxide; however, special attention
should be given since the association of products can also reduce the microhardness
of the dental enamel.
Clinical significance: The association between whitening toothpastes and mouth
rinses might be beneficial for maintaining color during 1 year after bleaching
treatment.
KEYWORDS
bleaching agents, color, hardness, tooth bleaching
wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals LLC. 1
2 SANTANA JORGE ET AL.
1 | I N T RO DU CT I O N
Esthetic appearance has become increasingly important nowadays,
and can affect psychological, social, and interpersonal relationships.
The color of teeth is one of the most determinant factors for patients'
satisfaction and self-esteem.1 Due to being a conservative approach,
tooth whitening has become the most popular esthetic treatment in
dentistry.2 In this procedure, gels with hydrogen or carbamide perox-
ide are employed and their application techniques vary according to
the concentration of the activating agent, which bleach teeth through
3
oxidation-reduction reactions of free radicals.
Currently, the technique of home bleaching with individual trays
is being increasingly used.4 In addition, the high level of demand for
this type of treatment has resulted in the growth of a market for
bleaching products, including bleaching toothpastes and mouth-
washes that can be easily found in supermarkets and drugstores,
referred in the literature as “over-the-counter” (OTC) products,5
which do not need a dentist's prescription for use.
OTC products have different whitening mechanisms. For mouth
rinses and strips, the mechanism is based on the presence of hydrogen
peroxide; while toothpastes focus on surface abrasion, removing sur-
face stains.6 The incorporation of chemical agents, such as hydrogen
peroxide in low concentrations, increase bleaching power by reacting
with chromogenic molecules, and dissolving tooth enamel/dentin
stains, producing significant color change.7
Literature shows that OTC agents, as toothpaste8,9 and mouth
10
rinse, are not as effective, by themselves, as the home bleaching gel.
However, due to their effectiveness in removing stains,6 they might
be helpful in the color maintenance after whitening procedures,
supervised by the dentist. In addition, it is important to evaluate not
only the influence of these products on color maintenance after
bleaching, but also their effect on tooth properties, especially the
hardness,11 predictor of the loss of mineral content of enamel,12 and
resistance to fracture.13
The aim of this study was to evaluate the maintenance of color
and microhardness of the dental enamel after home bleaching proce-
dure and 1 year after using the OTC products. The null hypothesis
was that the association of OTC products would produce no differ-
ence in the color and microhardness after home bleaching procedure,
irrespective of the association employed.
2 | MATERIALS AND METHODS
The sample size was based on data obtained from a pilot study
(n = 10) and determined on www.openepi.com, with a significant level
of 5%. The statistic power of the study was 93.06%.
Bovine teeth were cut (Isomet 100 Buehler, Illinois) in fragments
(6 × 6 × 2 mm) that were embedded in acrylic resin, with the buccal
surface parallel to the horizontal plane. The enamel surface of the
specimens was gently flattened using 600, 1200, and 2000 grit SiC
abrasive paper for 15 seconds, in order to uniform samples surface
roughness.
Color (Easyshade, VITA; Bad Säckingen, Germany) and micro-
hardness (HMV-2, Shimadzu, Tokyo, Japan) were then analyzed. For
color analysis, the standard observation followed the CIEDE 2000 sys-
tem, defined by the formula: ΔE00 = (ΔL/KL  SL) + (ΔC/
KC  SC)2 + (ΔH/KH  SH)2 + RT  (ΔC/KC  SC)X(ΔH/KH  SH)0.5, where
ΔL0 , ΔC0 , and ΔH0 are the differences in lightness, chroma, and hue
between two specimens and RT (rotation function) is a function that
accounts for the interaction between chroma and hue differences in
the blue region.
SL, SC, and SH are the weighting functions for the lightness,
chroma, and hue components, respectively. KL, KC, and KH are the
parametric factors according to different viewing parameters that
were set to 1.
Color measurements were made against a white background
(White Standard Sphere for 45
, 0
Reflectance and Color Gardner
Laboratory, Germany) and in a standardized lightbox (Gester Interna-
tional; Fujian Province, China) with a neutral-gray (Munsell N-7) back-
ground and under primary standard illuminant D65, which simulates
the light spectrum of the day.
After activation, 19 optical fibers of spectrophotometer were lit
and emitted a beam of light at 45
on the surface of the material. The
light is reflected at 0
and recorded as the coordinates L*, a*, and b*
specimens' values. Three color measurements were made for each
specimen, which were considered initial coordinate values. Further-
more, the CIELAB-based whiteness index (WID) was calculated by the
formula: WID = 0.511 L* − 2.324a* − 1.100b* to correlate the visual
perception of whitening, avoiding the subjective visual factor in dental
color measurement.14 Positive values of WID indicate higher white-
ness values, and low (or negative) values, indicate lower values of
whiteness.14
Knoop microhardness (HMV-2; Shimadzu, Tokyo, Japan) were
measured with a vertical static load of 25 g for 5 seconds at ×40 mag-
nification. Data were calculated by using the formula: KHN = 1, 451
d2
F
,
where KHN is Knoop Hardness number; F is 25 g, and d is the length
of largest diagonal indentation. Specimens were measured in three
segments: in the center and two marks at a distance of 1 mm to the
left and to the right, respectively. The means of these three measures
were considered as the initial microhardness values. The change in
microhardness (before and after each treatment) was calculated by:
KHN = KHNf − KHNi, where KHNf represents final microhardness
measurement and KHNi is the initial measurement.
After the initial measurements, samples were randomly assigned
into seven groups (n = 10) (Table 1) according to the treatment proto-
col, considering the interaction of the bleaching products (Table 2):
whitening 22% carbamide peroxide gel (22%CP); a toothpaste (con-
ventional, whitening, and whitening with peroxide); and mouth rinse
(conventional and whitening).
The whitening treatment with 22%CP was carried out as rec-
ommended by the manufacturer, for 14 days, simulating the gel appli-
cation by the patient for 1 hour per day. The gel was applied placing a
small drop (0.2 mL) in the center of the sample with a syringe, and
then it was better distributed and spread throughout the entire sam-
ple with an applicator to form a uniform layer.15 After 1 hour, the
SANTANA JORGE ET AL. 3

specimens were rinsed with distilled water, to completely remove the
product. Then, they were immersed in distilled water for 23 hours
until the next application. This procedure was performed for 14 days.
The simulated toothbrushing (Pepsodent, MAVTEC; Ribeirao Preto,
SP, Brazil) was performed using a toothbrush (Tek, Johnson & John-
son; Sao Jose dos Campos, SP, Brazil) according to ISO/DTS 145692
(Richmond et al, 2004) under 200 g load at 356 rpm and 3.8 cm path
with back and forth movements. Toothpaste (5 g) was diluted in dis-
tilled water (5 mL) (1:1 ratio) and the toothbrushing machine simulated
1 year of brushing performed by a healthy individual
(14.600 cycles).16 Afterward, fragments were washed in running
water, dried with absorbent paper, and stored separately in plastic
containers with 3 mL of distilled water for each fragment (37
C) until
final color and microhardness measurements were obtained.
To simulate 1 year of use of mouth rinse, samples were submitted
to 12 cycles of 1 minute of immersion. At the end of each cycle, they
were washed in running water, and then immersed in distilled water
for 29 minutes (37
C). This procedure was repeated for 30 days, total-
ing 360 cycles.17
After each treatment protocol, final color and microhardness
measurements were performed, according to the previously described
methodology.
After all the quantitative data was collected, normality was veri-
fied by Shapiro-Wilk test (P < .05), and data for color alteration were
statistically analyzed by a parametric test (one-way ANOVA, Tukey's
test, P < .05) and for the microhardness by Kruskal-Wallis, Dunn's
test, P < .05.

3 | RE SU LT S
TABLE 1 Groups distributions
The comparison of ΔE00 and ΔWID can be seen in Tables 3 and 4.
Groups Tray system Toothpaste Mouth rinse Regarding color change (ΔE00), there was difference (P < .05) between
1 Carbamide Conventional Conventional group 4 (22%CP + whitening toothpaste + whitening mouth rinse)
peroxide and group 7 (control: conventional toothpaste + conventional mouth
2 Conventional Whitening rinse). The other groups showed similar results to both groups. On the
3 Whitening Conventional other hand, there was no difference (P > .05) among the results of
4 Whitening Whitening color coordinates (Table 3).
5 Whitening + Conventional The WID analysis did not demonstrate difference (P > .05) among
peroxide the tested groups (Table 4). However, the values found in the WID
6 Whitening + Whitening analysis were higher than those found in the ΔE00, which may indicate
peroxide a greater perception of the color change.
7 No whitening Conventional Conventional Table 5 shows the microhardness (KHN) means and standard
agent
deviation (Kruskal-Wallis, Dunn's test, P < .05). Group 2 presented

TABLE 2 Material compositions

Treatment protocol Product Composition

22% carbamide peroxide
(22%CP)
Conventional toothpaste
Conventional mouth rinse
Whitening mouth rinse
Whitening toothpaste
Whitening toothpaste with
peroxide
Whiteness Perfect 22 (FGM;
Joinville, Santa Catarina, Brazil)
Sorriso Dentes Brancos (Colgate
Palmolive; Sao Bernardo do
Campo, Sao Paulo, Brazil). RDA:
68
Colgate Plax Classic (Colgate
Palmolive)
Listerine Whitening (Colgate
Palmolive)
Colgate Luminous White (Colgate
Palmolive). RDA: 175
Advanced White (Arm & Hammer,
Church & Dwight; St Paul,
Minnesota). RDA:106
Carbamide peroxide, neutralized carbopol, potassium nitrate, sodium fluoride,
moistener (glycol), deionized water
Calcium carbonate, water, glycerin, sodium lauryl sulfate, aroma, sodium
monofluorophosphate (1450 ppm fluorine), cellulose gum, tetra sodium
pyrophosphate, sodium bicarbonate, alcohol benzylic, sodium saccharin,
sodium hydroxide, limonene
0.05% sodium fluoride, cetylpyridinium chloride, water, glycerin, propylene
glycol, sorbitol, poloxamer 407, aroma, potassium sorbate, saccharin sodium,
citric acid, CI 16035, blue acid 3 (CI 42051)
0.05% sodium fluoride, water, glycerin, propylene glycol, sorbitol, tetra
potassium pyrophosphate, polysorbate 20, tetra sodium pyrophosphate,
citrate zinc, pvm/ma copolymer, aroma, benzylic alcohol, sodium fluoride
(225 ppm fluorine), saccharin sodium, blue acid 3 (CI 42051)
Sodium fluoride (1450 ppm fluorine), water, sorbitol, hydrated silica, PEG-12,
sodium lauryl sulfate, aroma, cellulose gum, potassium hydroxide, tetra
sodium pyrophosphate, phosphoric acid, cocainapropyl betaine, benzyl
alcohol, sodium saccharin, CI (77891), limonene
0.24% sodium fluoride, sodium bicarbonate, PEG-8, pyrophosphate tetra
sodium, PEG/PPG copolymer 116/66, sodium carbonate peroxide, silica,
sodium saccharin, flavor, water, sodium lauryl sodium lauryl sulfate
4 SANTANA JORGE ET AL.

TABLE 3 ANOVA test for each studied variable

Sum of squares df Mean square F(DFn, DFd) P value

ΔE00 117.9 6 19.7 F(6. 63) = 2.59 .0265
ΔL 258.5 6 43.1 F(6. 63) = 1.77 .1205
Δa 11.6 6 1.93 F (6. 63) = 0.48 .8218
Δb 189.3 6 31.5 F (6. 63) = 1.29 .2771
ΔWID 829.9 6 138.3 F (6. 63) = 1.37 .2408

TABLE 4 Comparison of CIELab color coordinates and whiteness index (ΔWID) values among the groups tested

G1 G2 G3 G4 G5 G6 G7
ΔE00 9.25 (2.87) AB 9.71 (2.66) AB 8.15 (1.73) AB 10.97 (2.77) A 10.50 (2.32) AB 10.37 (3.35) AB 7.06 (3.25) B
ΔL 6.98 (4.83) 6.56 (3.32) 9.22 (7.73) 4.88 (3.31) 8.74 (5.68) 6.97 (3.98) 3.26 (4.19)
Δa −4.02 (2.07) −5.02 (2.21) −4.35 (2.18) −4.96 (2.61) −4.77 (1.68) −4.58 (0.77) −3.91 (2.04)
Δb −9.42 (3.32) −12.00 (4.91) −10.19 (5.82) −10.41 (4.72) −12.41 (5.86) −11.43 (5.14) −7.20 (4.46)
ΔWID 23.27 (7.02) 29.13 (13.87) 26.03 (11.96) 25.46 (11.96) 29.2 (9.77) 27.6 (8.42) 18.68 (8.29)

Note: Different letters in the line indicate statistically significant difference (P < .05). There were no differences between groups (P > .05) when compared
ΔL, Δa, Δb, and ΔWID.

TABLE 5 Comparison of median values (confidence interval) of microhardness (ΔKHN) among the groups

G1 G2 G3 G4 G5 G6 G7
ΔKHN 77.7 −66.0 69.3 66.5 98.3 116.9 44.2
(50.5; 233.2) (−461.3; 3.6) (11.8;184.0) (−71.5; 318.2) (−45.6; 362.1) (−93.7; 302.9) (−49.8; 125.3)
A B A A A A AB

Note: Different letters indicate statistically significant difference (P < .05).

negative values, demonstrating decrease in microhardness after treat-
ments, different from the other groups (P < .05), except group 7. All
other sample's treatments changed the microhardness, but with no
difference (P > .05) among groups.
4 | DISCUSSION
The aim of this study was to evaluate the use of OTC agents on the
maintenance of color and microhardness of the dental enamel after
home bleaching procedure. The null hypothesis tested was that there
would be no difference in the maintenance, irrespective of the associ-
ation of products. Considering the results, it was not possible to
accept this hypothesis because significant differences were found for
color change (ΔE00) between the group that used 22%CP + whitening
toothpaste + mouth rinse and the control group. In addition, the
microhardness evaluation demonstrated that the association of OTC
products with 22%CP could result in lower microhardness values, as
seen in the group that used conventional toothpaste + whitening
mouth rinse after the home bleaching procedure.
Whitening toothpaste can help on the maintenance of tooth color
due to the presence of many abrasive particles in its composition,18
such as alumina, dicalcium phosphate dihydrate, or hydrated silica; the
latter found in the whitening toothpaste used in the present study.
These abrasive particles are incorporated to promote dental enamel
wear and whitening effect. The abrasive particles' size and structure
may influence toothpaste's RDA value, which is directly related with
the surface roughness, wear, and consequently, in the light reflection
of restorative materials19; however, the toothbrush action and other
facts as saliva's ions and proteins minimize this effect.19 The tooth-
brushing simulation performed in this study may have minimized the
abrasive effect of tested toothpastes, even with different RDA
(Table 2), as there was no interference in Delta E between the experi-
mental groups. In addition, the whitening toothpastes also have
enzymes that dissolve stains caused by proteins adhered to the
enamel, leading to stain removal.20
Besides the abrasives, other toothpastes, as the one employed in
the research (whitening toothpaste with peroxide), may contain per-
oxides in their composition, which aims to promote a greater
bleaching effect than that produced by abrasive particles. Neverthe-
less, the low concentration of the peroxide on toothpastes may not
promote a significantly greater effect than that already found in the
peroxide-free bleaching toothpastes. What is more, the peroxide
remains in contact with the tooth only during the time of brushing; a
shorter time than the period of contact of the gel, which is also used
in higher concentration.
These toothpastes act on extrinsic stains and do not significantly
affect the intrinsic tooth color,7 while the bleaching treatment with
carbamide peroxide can produce color change resulting from its
decomposition into urea and peroxide, which diffuse through the
tooth causing oxidation and the reduction of the intrinsic organic pig-
ments in dentin, responsible for efficient tooth bleaching.21
SANTANA JORGE ET AL.
As regards the effectiveness of mouth rinses with bleaching
agents, studies have shown divergent results. A previous study dem-
onstrated similar color changes between groups submitted to
bleaching mouth rinses, used for 12 weeks, when compared with
home bleaching groups using 10% carbamide peroxide.18 In contrast,
other studies have reported that these mouth rinses did not show sig-
10,22
nificant bleaching effects, which is in agreement with the results
found in the present study. Teeth treated with a bleaching mouth
rinse showed no significant differences (P > .05) when compared with
the nonbleaching agent groups.
The bleaching mouth rinses usually contain citrate and potassium
or sodium pyrophosphate, components that have bleaching potential
by removing surface glaze stains. Other formulations also contain
hydrogen peroxide at low concentrations, or sodium
hexametaphosphate, an anti-tartar agent, which prevents the formation
of stains.23 The bleaching mouth rinse used in this study contains
tetrapotassium pyrophosphate, tetrasodium pyrophosphate, and zinc
citrate as bleaching/stain remover components. Nevertheless, since
they are in contact with the teeth for a very short period of time com-
pared with other types of products, the effectiveness and action of
their components may be limited. A previous study demonstrated that
the period of exposure to bleaching mouth rinses was a determinant
6
factor in the effects obtained.
The color alteration resulted from an increase in ΔL and a
decrease in Δb and Δa indicating increase in lightning and decrease
on yellow and red chroma. However, there was no difference among
the groups, considering these coordinates. Despite these results, the
perception of whitening (WID) was higher or there were no differ-
ences when other OTC products were used.
The association of the home bleaching gel with OTC products
influenced the microhardness of the samples. Group 2 (22%CP
+ conventional toothpaste + whitening mouth rinse) presented a
wide range of value, negative, indicating a decrease in the property.
Studies have shown that bleaching products can have deleterious
effects not only on enamel microhardness but also on abrasive wear
and surface roughness of teeth.18 The conventional toothpaste pre-
sents sodium monofluorophosphate (SMFP) in its composition, while
the whitening toothpaste contains sodium fluoride. Unlike sodium
fluoride, the SMFP is not an ionic fluoride salt, but rather a cova-
lently bound compound that requires enzymatic activation by a sali-
vary enzyme to release fluoride. As an in vitro study, this does not
occur. On the contrary, during use, the sodium fluoride dissociates
to provide to provide a highly reactive fluoride ion, achieving anti-
caries effect.
In group 2, the bleaching effect of carbamide peroxide was asso-
ciated to the bleaching mouth rinse, which has alcohol in its composi-
tion. This substance, used as a solubilizing and preservative agent,
although not promoting deleterious effects on enamel,24 may produce
synergistic effect of the components, leading to a lower micro-
hardness. On the other hand, the presence of fluoride in the bleaching
mouth rinse and the conventional toothpaste could provide a
remineralizing effect. Nonetheless, higher concentration of free fluo-
ride would be necessary.25
5
As mentioned before, mouth rinses are exposed to the oral cav-
ity for a short period and must have substantivity to achieve their
best action. Nonetheless, some cationic antiseptics, such as
cetylpyridinium chloride-based (conventional mouth rinse) solutions,
can be inactivated by anionic chemical compounds,26 such as sodium
lauryl sulfate and pyrophosphate, which are components found in
the whitening toothpaste. In addition, pyrophosphate is an ingredi-
ent that acts on mineral chelation and inhibition of ectopic minerali-
zation. It interacts greatly with the calcium in both solutions and on
surfaces by pairing of the ions, in which the positive charge of cal-
cium attracts the negative charges of oxygen in the phosphate
anions.27
Thus, it can be suggested that in group 2, the pyrophosphate
belonging to the mouth rinse may have sequestered the calcium
from the enamel surface that had already been previously deterio-
rated due to the effect of 22%CP, therefore decreasing the
microhardness.
The other groups presented an increase in microhardness
values. Bleaching products are known to be capable of causing tran-
sient demineralization; nevertheless, some products have sodium
fluoride or SMFP in their composition. These two types of fluoride
are dental enamel remineralizing substances, widely used in various
toothpaste and mouth rinses for caries prevention.28,29 The fluoride
ions are able to replace the hydroxyl ions of the hydroxyapatite of
the tooth to produce fluorapatite, making it more resistant to acid
dissolution.30 The presence of these fluorides in the products may
explain the increase in microhardness values of the samples after
the treatments.
In an in vitro study, the protocols of use of the products, mode
and frequency of toothbrushing, time of use of the mouth rinses,
and temperature can be well controlled. However, the oral dynamics
and the oral hygiene habits among users are very diverse. What is
more, it was not possible to analyze the action of saliva as a
remineralizing and buffering agent on the microhardness of dental
enamel. Artificial saliva is known to be capable of increasing the
color change of teeth and materials,31 the reason why the color sta-
bility in this environment was not tested, which was a limitation of
the study.
Nonetheless, although the literature shows a reduced
bleaching effect for OTC products, the present study showed that
the association between these whitening toothpastes and mouth
rinses might be beneficial for maintaining color during 1 year after
bleaching treatment. Thus, further clinical studies are rec-
ommended in order to better elucidate the effects of OTC
products.
5 | CONC LU SIONS
The present study demonstrated that regardless of the protocol
employed, the OTC products could maintain, for a year, the tooth
bleaching produced after the home bleaching procedure with carbam-
ide peroxide; however, special attention should be given since the
6 SANTANA JORGE ET AL.
association of conventional toothpaste with whitening mouth rinse
can reduce the microhardness of the dental enamel.
ACKNOWLEDGMENTS
The study was supported by Sao Paulo Research Foundation
(FAPESP), Brazil, grant number 2017/09295-4. The authors deny any
conflicts of interest related to this study.
DIS CLOSUR E STATEMENT
The authors do not have any financial interest in the companies
whose materials are included in this article.
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