Clinical Oral Investigations

https://doi.org/10.1007/s00784-021-04128-8

ORIGINAL ARTICLE

Is the at‑home bleaching treatment applied only on the lingual

surface as effective as that on the buccal surface? A randomized
clinical trial
Luciana Mendonça Silva1 · Ítalo Augusto da Costa Lacerda1 · Daniela Bandeira dos Santos2 ·
Fernando José Herkrath3 · Karine Letícia da Silva4 · Alessandro Dourado Loguercio4 · Leandro de Moura Martins1

Received: 26 May 2021 / Accepted: 3 August 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objectives This double-blind randomized clinical trial compared the effectiveness and bleaching sensitivity (BS) of at-home
dental bleaching performed on the buccal surface and on the lingual surface.
Methods Using a split-mouth design, 25 patients were assigned to two bleaching groups: 10% hydrogen peroxide (White
Class 10%, FGM) applied once daily for 60 min to the buccal surface (BSB) and 10% hydrogen peroxide (White Class 10%,
FGM) applied once daily for 60 min to the lingual surface (LSB), both for 14 days. The color was evaluated before bleaching,
after the first and second weeks, and 1 month after the bleaching using Vita Classical and Vita Bleachedguide scales and a
Vita Easyshade spectrophotometer. BS was recorded daily using a 0–4 numerical rating scale and a 0–10 visual analogue
scale. The following statistical tests were used: color changes (Mann–Whitney), absolute risk of BS (McNemar’s exact), and
the intensity of BS (Mann–Whitney). In all statistical tests, the significance level was 5%.
Results Significant bleaching was observed after the end of bleaching in both groups, with higher bleaching effectiveness
for BSB when compared to LSB (p < 0.05). Regarding BS, no significant difference was observed between groups (p = 1.00).
Conclusions The 10% hydrogen peroxide (White Class 10%, FGM) applied in at-home bleaching performed on the lingual
surface did not promote a similar result of color change compared to on the buccal surface. Regarding BS, there was no
significant difference between the groups.
Clinical relevance The at-home bleaching performed on the lingual surface promotes a lower result in the color change. BS
is similar between the groups.
Clinical trial registration number RBR-283byt

Keywords Dentin sensitivity · Hydrogen peroxide · Tooth bleaching · Randomized clinical trial

Introduction

Dental bleaching is one of the most common aesthetic pro-

* Alessandro Dourado Loguercio
aloguercio@hotmail.com
1
School of Dentistry, Graduate Program in Dentistry, Federal
University of Amazonas, Manaus, AM, Brazil
2
School of Dentistry, Federal University of Amazonas,
Manaus, AM, Brazil
3
Instituto Leônidas E Maria Deane, Fundação Oswaldo Cruz,
State University of Amazonas, Manaus, AM, Brazil
4
Departament of Restorative Dentistry, State University
of Ponta Grossa, Ponta Grossa, PR, Brazil
cedures performed in dentistry due to its safety, conservative
technique, and low cost [1, 2]. It is the treatment of choice
for reducing patients’ dissatisfaction with dental discolora-
tion [3].
Among dental bleaching techniques, at-home dental
bleaching presents an easy protocol and reduced chair-
time compared to in-office bleaching [4]. It also presents a
lower risk of bleaching sensitivity (BS) [2] mainly because
it uses lower concentrations of hydrogen peroxide (HP) [5,
6]. These advantages make the at-home technique the most
suitable for bleaching teeth [5, 7].

13
Vol.:(0123456789)

At-home bleaching via the application of carbamide
peroxide in a tray became popular in 1989 with the pub-
lication of Haywood and Heymann’s study [8], in which
the authors indicated the use of a vacuum-formed custom-
fitted tray, approximately 1-mm thick, which is filled with
bleaching gel and used overnight for up to 6 weeks. The
usual recommendation is to apply the bleaching gel to the
buccal surface, as is done during in-office bleaching. In
addition, the creation of reservoirs on the buccal surface
was recommended to provide a space for the viscous mate-
rial to reside and to seat the tray completely without apply-
ing pressure to the teeth [9].
This bleaching method became very popular worldwide,
with clinical studies from various research groups show-
ing its effectiveness and safety [1, 10–14]. Unfortunately,
some aesthetic procedures such as ceramic laminates do
not allow the performance of bleaching procedure after
cementation, affecting the long-term final aesthetic result.
Therefore, to improve the final aesthetics of ceramic lami-
nates because the color of the dental substrate interferes
with the final visualization of these restorations, some
authors [15, 16] have suggested applying the bleaching
gel to the lingual surface to promote the bleaching of the
underlying dental structure. In this case report, the authors
showed that, although bleaching does not change the color
of laminate ceramics [17, 18], the bleaching of teeth cov-
ered by ceramic veneers can change the apparent color of
the veneers [15].
Because bleaching agents can diffuse through enamel
and dentin, releasing oxygen and breaking the double bonds
of organic and inorganic components within the dentinal
tubules and causing the bleaching effect [19], the application
of the bleaching gel to the lingual surface might promote
the same efficacy and the same levels of BS observed when
the gel is applied to the buccal surface. Some studies have
already demonstrated that bleaching gel, even when it is not
in direct contact with the buccal surface of the teeth, can
cause bleaching [20–22]. However, the literature contains no
evidence of the efficacy of bleaching and BS when bleaching
gel is applied to the lingual surface.
To the authors’ knowledge, no clinical trial comparing
the effectiveness and BS of at-home dental bleaching per-
formed on the lingual surface to that performed on the buc-
cal surface exists. Therefore, the aim of this clinical trial is
to evaluate the efficacy and BS of at-home bleaching per-
formed with bleaching gel applied only to the lingual surface
compared to the same bleaching applied only to the buc-
cal surface. The following null hypotheses were tested: (1)
there will be no difference in the effectiveness of bleaching
when comparing both techniques; and (2) there will be no
difference between the absolute risk and the BS intensity
of at-home bleaching performed with different application
techniques.
13
Clinical Oral Investigations
Material and methods
Ethics approval and protocol registration
This clinical trial was approved (protocol number 2.620.588)
by the Scientific Review Committee for the Protection of
Human Participants of the Federal University of Amazonas
(Manaus, Brazil), and was registered in the Brazilian Clini-
cal Trials Registry (ReBEC) under the number RBR-283byt.
The present study was prepared using the protocol estab-
lished by the Consolidated Standards of Reporting Trials
Statement [23].
Trial design, settings, and locations of data
collection
This was a controlled, parallel, double-blind, randomized
clinical trial, in which the evaluator and statistician were
blinded to the group’s assignment. One of the researchers,
who was not involved in the clinical stages of dental bleach-
ing, performed the randomization. This study was performed
from May 2018 to September 2019 at the School of Den-
tistry of the Federal University of Amazonas.
Recruitment
All the participants signed an informed consent form before
being enrolled in the study. Before the beginning of the
bleaching procedure, all the volunteers received a dental
prophylaxis with pumice powder and water in rubber cups.
Recruitment was performed by placing a written advertise-
ment on the university walls.
Eligibility criteria
Volunteers included in this clinical trial were between 18
and 40 years old and had good general, observed during the
anamnesis, and oral health (no active decay teeth or peri-
odontal disease, as well as extraction to be done), evaluated
during the dental exam. Also, the participants were required
to have six upper anterior teeth free of restorations, caries,
or periodontal diseases, and could require to have at least
two central incisors or canines with shade C2 or darker as
judged by comparison with a value-oriented shade guide
(Vita Classical, Vita Zahnfabrik, Bad Säckingen, Germany).
Participants with anterior restorations or dental prosthe-
sis, with orthodontics braces, severe crowding, recession,
dentine exposure, presence of intrinsic spots, bruxism, or
presence of cracks in teeth, and participants who report
severe sensitivity during treatment were not included in the
study. In addition, pregnant and lactating women, smokers,
Clinical Oral Investigations

alcoholics, and participants with health problems like patho-
logical, physiological, and drug alterations, and participants
taking anti-inflammatory drugs were also excluded from the
study.
Sample size calculation
The primary outcome was color change (ΔE). To exclude
an average difference of ΔE = 3 (50:50% acceptability limit)
with a power of 90% and an alpha of 5%, considering that
the standard deviation of ΔE is approximately 3 [24], a
minimum of 22 participants in each group were required to
demonstrate equivalence in color change between at-home
dental bleaching performed on the buccal surface in com-
parison to the lingual surface. To consider a possible loss of
patients, 15% of the sample was added. Therefore, the final
calculation was 25 participants in a total of 25 once it is a
split-mouth design trial [24].
Randomization and allocation concealment
The randomization was performed in blocks (block sizes
of 2) with an equal allocation ratio to form the allocation
list for the two comparison groups. The randomization list
was prepared through the website www.s​ ealed​ envel​ ope.c​ om.
Opaque, sealed, and consecutively numbered envelopes con-
taining the identification of the groups were prepared by a
third researcher not involved in the research protocol. The
identification number on the envelope was related to the
treatment protocol that should be performed by the patient.
The envelopes were only opened before implementation.
Study intervention
Alginate impressions (Avagel, Dentsply, Petrópolis, RJ,
Brazil) were made of each subject’s maxillary and man-
dibular arch. After disinfection with 2% glutaraldehyde for
10 min, the impressions were filled with dental stone (Asfer,
Asfer Indústria Química Ltda., São Caetano do Sul, SP,
Brazil), and a 0.9-mm soft vinyl material (FGM, Joinville,
SC, Brazil) was used to fabricate the custom-fitted tray to
hold the bleaching gel. The excess materials from the labial
and lingual surfaces were trimmed 1 mm from the gingi-
val junction. After the preparation of the silicone bleach-
ing trays, windows were made on the vestibular surfaces
of the anterior teeth of one of the maxillary hemiarches,
following randomization, so that the gel was applied only
on the lingual surface of teeth, while the opposite hemiarch,
windows were made on the lingual surfaces and the gel was
applied on the buccal surface (Fig. 1). Only the maxillary
arch was included in the present evaluation. However, after
finishing the present study, it was necessary to bleach the
mandibular arch to achieve complete patient satisfaction.
This is the main reason to fabricate the custom-fitted tray of
the mandibular arch.

Blinding

This study was a double-blind clinical trial in which the

evaluator who performed the color assessments was blinded
to the treatments and the statistician was blinded to the study
groups. Participants and operators could not be blinded to
the study groups. The participants were not blinded because
they could easily identify the two bleaching protocols used
(split-mouth) and operators were not blinded because they
should explain the protocols to patients on how to use the
gels in each hemiarch. In order to maintain evaluator blind-
ing, the two protocols— 60 min on the lingual (LSB) or
on the buccal surface (BSB), with 10% hydrogen perox-
ide (White Class 10%, FGM, Joinville, SC, Brazil)—were Fig. 1  Tray used in the present study. Observe in A, windows were
explained to the patients by a researcher not involved in the made on the vestibular surfaces of the anterior teeth (right side), fol-
lowing randomization, so that the gel was applied only on the lingual
implementation of the study and were identified as codes “1”
surface of teeth, while on the left side, windows were made on the
or “2.” Only the researcher responsible for the study knew lingual surfaces and the gel was applied on the buccal surface. In B,
the coding system. the tray in position

13

The participants received the bleaching tray, the bleach-
ing gel, and their respective instructions of time-of-use pro-
tocol by a researcher not involved in the implementation of
the study. The participants were instructed to wear the tray
with the bleaching agent for 60 min, both on the buccal and
lingual surfaces according to the randomization, once a day
for 14 days [25, 26]. The participants were also instructed
to remove the tray after each bleaching period and to wash it
with water. Verbal instructions about oral hygiene were also
provided, encouraging participants to brush their teeth regu-
larly with fluoridated toothpaste containing no whitening
components (Sorriso Fresh, Colgate-Palmolive, São Paulo,
SP, Brazil). There was no diet restriction of the volunteers
[27].
As a measure of adherence to the experimental protocol,
participants were given a diary in which they were asked to
take notes of the number of times they used the tray during
the treatment. If they wore the bleaching tray 14 times, this
would result in a 100% adherence to the protocol.
Color evaluation
Color evaluation was performed by two calibrated evaluators
at baseline, after the first and second weeks of bleaching, and
at 1-month post-bleaching. If disagreements occurred during
the evaluation, the evaluators needed to reach a consensus.
The color evaluation was performed using three differ-
ent instruments, two value-oriented shade guide units Vita
Classical (Vita Zahnfabrik, Bad Säckingen, Germany) and
ΔE00 (CIEDE2000) = (ΔL∕kLSL)2 + (ΔC∕kCSC)2 + (ΔH∕kHSH)2 + RT(ΔC ∗ ΔH∕SC ∗ SH)
[
and
WI D = (0.511 × L ∗) − (2.324 × a ∗) − (1, 100 × b ∗)
The tooth color measurements were performed for all
the maxillary anterior teeth (central and lateral incisors and
canines). For statistical purposes, the measurement area of
interest for shade matching was the middle third of the facial
surface of the anterior central right incisor.
Bleaching sensitivity evaluation
The volunteers were instructed to record the bleaching-
induced sensitivity daily during bleaching for 14 days.
Each participant was asked to indicate the numerical
value of the degree of sensitivity using a 5-point Numeric
13
Clinical Oral Investigations
Vita Bleachedguide 3D-MASTER (Vita Zahnfabrik, Bad
Säckingen, Germany), and a spectrophotometer (Easyshade,
Vita Zahnfabrik).
For color evaluation with the Vita Classical scale, its 16
tabs were arranged from the highest (B1) to the lowest (C4)
value. The 24 tabs of VITA Bleachedguide 3D-MASTER’s
are already organized from the highest (0M1) to lowest
(5M3) value. Each tab was given an ordered number, 1 to
16 for the VITA Classical or 1 to 24 for the VITA Bleached-
guide. Although this scale is not linear in the truest sense, for
the purpose of analysis, the changes were treated as though
they represented a continuous and approximately linear
ranking. The color was evaluated on the middle third of the
buccal surface of the anterior central right incisor. Color
changes from the beginning of the bleaching procedure to
the individual recall times were performed by calculating the
change in the number of shade guide units (ΔSGU).
For color measurement with the spectrophotometer,
a dense silicone (Flex-sil, Technew, Rio de Janeiro, Bra-
zil) was used to prepare a guide with a window for all the
maxillary anterior teeth, so that color evaluation could be
standardized at the different time assessments. CIELab (ΔE)
parameters were recorded, where L* represents the value
from 0 (black) to 100 (white), a* represents the dimension
along the red-green axis, and b* the dimension along the
yellow-blue axis [25, 26, 28]. The color change at the differ-
ent time assessments was calculated using the CIELab (ΔE),
CIEDE 2000 (ΔE00), and Whiteness Index (­ WID) formulas
[26, 27, 29, 30]:
]1∕2
ΔEab (CIELab) = (ΔL ∗)2 + (Δa ∗)2 + (Δb ∗)2
[
]1∕2
Rating Scale (NRS), where 0 = none, 1 = mild, 2 = moder-
ate, 3 = considerable, and 4 = severe [7, 26, 31, 32]. Also,
they were instructed to record the pain intensity with a
vertical line across the Visual Analogue Scale (VAS), a
horizontal 0–10-cm scale, where 0 = no sensitivity and
10 = severe sensitivity [7, 26, 32]. The distance in mil-
limeters from the zero end was measured with the aid of
a millimeter ruler.
The worst score from the NRS scale and the highest
numerical value obtained in the VAS scale during the
entire bleaching treatment were considered for statistical
purposes, in such a way that only a single value was taken
from the 2-week treatment. The values were arranged into
two categories: absolute risk of BS and overall BS inten-
sity. The absolute risk of BS represented the percentage of
Clinical Oral Investigations

Fig. 2  Flow diagram of study

design phases including enroll-
ment and allocation criteria

volunteers who reported BS at least once during bleaching Results

treatment.
Statistical analysis
The analysis followed the intention-to-treat protocol and
involved all participants who were randomly assigned [23]
(Fig. 2). In cases of missing data, the last observation was
considered.
The data were first analyzed using the Shapiro–Wilk test
of normality to assess whether the data followed a normal
distribution. After that, the color changes between groups
(ΔSGU on both scales, ΔEab, ΔE00, and W ­ ID) at each time
were compared using a Mann–Whitney test. The absolute
risks of BS of both groups were compared by McNemar’s
exact test (α = 0.05), and the relative risk as well as the con-
fidence interval (CI) was also calculated. For comparison
of BS intensity (NRS and VAS data) of both groups, the
worst score of each group during all days of treatment was
taken into consideration. After that, the Mann–Whitney test
was applied. In all statistical tests, the significance level was
0.05 and the statistician was blinded to the study groups.
We performed all analyses by using SigmaPlot version 12.0
software (Systat Software).
Characteristics of participants
Thirty-seven patients were examined, and 25 were included.
Twelve patients were excluded mainly due to tooth color
(shades lighter than C2 or previous bleaching) or because
they did not meet some of the inclusion criteria (Fig. 2). The
demographic characteristics of the sample are described in
Table 1. The mean color at the baseline, according to Vita
Classical scale, was 12.2 ± 2.1 SGU for the lingual surface
bleaching (LSB) group and 12.4 ± 1.7 SGU for the buccal
surface bleaching (BSB) group. The mean age of the volun-
teers was 23 years in both groups. As for gender distribution,
Table 1  Baseline characteristics of the participants included in this
clinical trial
Characteristics Lingual surface Buccal
bleaching surface
bleaching
Age (mean ± SD, years) 23.7 ± 4.3 23.7 ± 4.3
Baseline color (mean ± SD, 12.2 ± 2.1 12.4 ± 1.7
SGU)
Abbreviation: SGU, shade guide units

13
 Clinical Oral Investigations

the majority of participants included in the sample were Table 3  Comparison of the number of patients who experienced
female (72%). bleaching sensitivity at least once during the two different bleaching
regimens along with absolute risk

Adherence to the protocol
Adherence to the protocol was 100%. No participant discon-
tinued treatment or was lost during follow-up.
Color evaluation
A significant whitening effect was observed in both study
groups under all evaluation methods used. However, a sig-
nificant and lower bleaching effect was observed for the
LSB group when compared to BSB when the subjective and
objective color measurements were used (Table 2; p < 0.02).
The significant differences for all color evaluation tools
showed that bleaching effectiveness was not equivalent
between the groups, mainly because the mean difference
values observed were superior to the 50:50% perceptibility/
acceptability threshold for 4 of the 5 scales used (Table 2) [24].
Bleaching sensitivity
Regarding the absolute risk of BS, no significant difference
was observed when 10% hydrogen peroxide was applied to
the LSB and BSB groups (Table 3; p = 1.00). Also, there was
no statistically significant difference between the groups for
both pain assessment scales when BS intensity was evalu-
ated (NRS; Table 4; p > 0.83 and VAS; Table 4; p > 0.81).
Discussion
According to Haywood [16], at-home bleaching on the lingual
surface could be considered a useful technique for cases in
which veneers are applied. In these cases, bleaching treatments
may be used to re-bleach teeth if there is a color rebound, as
the darkened dental structure can modify the color of these
restorations. Therefore, it can further lighten the apparent color
of the placed veneers along with the color of the underlying
substrate [15], increasing the long-term aesthetics.
However, although our initial idea was to obtain signifi-
cant bleaching in teeth restored with ceramic laminates, in
Treatment Bleaching sensi- Absolute risk* Relative risk
tivity (95% CI) (95% CI)
(number of
patients)
Yes No
LSB 18 7 72 (52–85) 1 (0.7–1.4)
BSB 18 7 72 (52–85)
Abbreviation: CI confidence interval; *test McNemar; p = 1.00
this study, we evaluated at-home dental bleaching in patients
with sound teeth to observe the behavior of HP in terms
of bleaching effectiveness and bleaching-induced BS when
applied to the lingual surface.
The study’s results indicate that some degree of bleach-
ing was achieved when 10% HP was applied on the lingual
surface. However, this bleaching pattern was inferior when
compared to that of other clinical studies [25, 26, 32], lead-
ing the authors to refuse the first null hypothesis.
For example, in the present study, ΔSGU of 2 (Vita
Classical) and 5 (Vita Bleachedguide) units were observed
after 2 weeks of bleaching, but Chemin et al. [32] observed
bleaching of approximately 4 and 6.7 units for the Vita Clas-
sical and Vita Bleachedguide, respectively. In another study,
Cordeiro et al. [26] observed a bleaching of 5.6 and 8.2 units
for the same scales. However, a similar whitening effect was
observed when the results from the BSB group were com-
pared with those in the literature [26, 32]. The color change
values observed for BSB group were superior to the 50:50%
perceptibility/acceptability threshold [24] when compared to
those for the LSB group in the present study.
This can probably be explained because the bleaching
gel containing 10% HP was applied to the lingual surface.
There are some differences when enamel and dentin thick-
nesses are compared in buccal and lingual surfaces [33, 34].
Although less enamel is present in the lingual surface com-
pared to the buccal surface, the amount of dentin is higher
in the former [33, 34]. Because the bleaching effect is more
related to the dentin substrate, less whitening was expected
to occur in the lingual group.

Table 2  Color change in shade Color evaluation tools LSB BSB Mean differences (95% CI) p-value*
guide units (SGU for Vita
Classical, Vita Bleachedguide), Vita Classical 2.2 ± 1.8 4.6 ± 1.5 2.4 (1.46 to 3.34) p < 0.001
ΔEab, ΔE00, and ­WID
Vita Bleachedguide 5.0 ± 3.1 8.2 ± 1.7 3.2 (1.78 to 4.62) p < 0.001
(means ± standard deviations)
between baseline vs. 30 days ΔEab 10.8 ± 5.3 14.5 ± 4.7 3.7 (0.85 to 6.55) p = 0.023
after bleaching for the two ΔE00 7.1 ± 3.6 10.2 ± 3.2 3.1 (1.16 to 5.04) p = 0.006
treatment groups WID 29.7 ± 22.3 43.3 ± 10.4 13.6 (3.71 to 23.49) p < 0.001
*
Mann–Whitney test

13
Clinical Oral Investigations

Actually, this could be partially explained by Fick’s second Interestingly, although a lower whitening effect was observed
law of diffusion, which states that the diffusion of a molecule is for the lingual surface group when compared to the buccal sur-
proportional to the surface area, diffusion coefficient, and con- face group, no significant difference was observed regarding
centration, and that it is inversely proportional to the diffusion the absolute risk and intensity of BS, leading the authors to not
distance [35]. Because it has been suggested that the diffusion refuse the second null hypothesis. Bleaching-induced sensitiv-
of hydrogen peroxide into the dentin follows Fick’s second law ity is the most common adverse effect of bleaching procedures
[36], in the lingual group, the hydrogen peroxide molecules must reported by patients, and it is also observed for at-home den-
travel a considerable distance to achieve some degree of bleach- tal bleaching [7, 28, 31, 32, 37, 39]. HP has a low molecular
ing in the buccal area compared to the buccal group. weight, which is associated with its rapid diffusion through
Despite this, hydrogen peroxide can diffuse through dental tissues. It reaches the pulp quickly, promoting bleaching-
enamel and dentin. This is necessary to break the double induced sensitivity [19]. This occurs even when low amounts
bonds of organic and inorganic components within the den- of HP bleaching gel are applied [40].
tinal tubules [19]. The amount of bleaching gel or applica- Although some anatomical differences can be seen between
tion time seems insufficient to guarantee a whitening effect enamel and dentin in the buccal and lingual surfaces [33, 34],
similar to the results observed for the buccal surface group. possibly indicating that the HP takes longer to reach the pulp
Several studies showed that the higher the gel concentration in the lingual surface, in this study, the BS observed in both
and prolonged time of application on the dental surface, the groups was similar. Moncada et al. [41] indicated that teeth with
greater the color change that can be expected [32, 37, 38]. reduced dentin thickness are not more susceptible to BS than
Therefore, professionals should extend the time of use those with greater thickness. This led us to believe that regard-
for each patient to achieve satisfactory effects. In the case of less of the surface to which HP gel is applied, BS would be the
at-home dental bleaching, the use of the tray for longer than same because the bleaching gel can reach the pulp in equal time
2 weeks might promote better color results when the gel is and proportion, regardless of where it is applied.
applied to the lingual surface. However, studies should be In fact, a high risk of BS (around 72%) was found for
conducted to prove this hypothesis. both groups in the present study. This is in line with several
However, it is noteworthy that even though the bleaching clinical studies that evaluated 10% HP for at-home bleaching
procedure was performed on the lingual surface in one group, [26, 32, 42, 43]. However, most patients experienced mild
color was evaluated on the buccal surface in both groups. This BS, which is in accordance with other studies that performed
effect may have affected the observed color change results in the at-home dental bleaching [7, 32, 37], mainly when compared
lingual group. In addition, the difficulty of accessing and evalu- to in-office bleaching [5].
ating color on the lingual surface, as well as the lack of studies The fact that a hydrogen peroxide gel applied to the palatal
on the diffusion of HP applied on the lingual surface, prevented surface can bleach the buccal surface without increasing the
us from predicting the effect of this phenomenon in this study risk of BS demonstrates that hydrogen peroxide’s diffusion
with certainty. Further studies are needed to verify these aspects. mechanism remains unclear. Diffusion through the inter-
prismatic spaces, followed by the absorption of the terminal
Table 4  Means and standard deviation (SD) of the bleaching sensi-
tivity intensity at the different assessment points for the study groups branch of the dentinal tubules, partially explains the possibil-
and the statistical comparison ity of multidirectional travel for hydrogen peroxide. Therefore,
the authors hypothesize that its great diffusion capacity occurs
Time assess- LSB BSB Mean differences p value*
ments (95% CI) because of accumulation in the dentin-enamel junction (DEJ),
as demonstrated by Kwon et al. [36]. This accumulation in the
Numerical rate scale DEJ would have the capacity to diffuse hydrogen peroxide
First week 1.1 ± 1 1.1 ± 1 0.0 (− 0.57 to p = 0.89 throughout the coronal pulp extension.
0.57)
Although both tooth sensitivity scales (NRS and VAS)
Second week 0.6 ± 1 0.7 ± 1 − 0.1 (− 0.67 to p = 0.83
0.47) achieved the same result in the present study, there is no
Overall 1.2 ± 1 1.2 ± 1 0.0 (− 0.57 to p = 0.83 consensus in the literature, which is the best one to be
0.57) used [3]. Therefore, it is worth mentioning the psycho-
Visual Analogic Scale metric properties of each scale. The VAS measures pain
First week 1.7 ± 1.8 1.9 ± 2 0.0 (− 0.57 to p = 0.91 on a continuous scale, whereas the NRS evaluates pain on
0.57) a discrete, 0 to 4 scale, with the smallest unit of change
Second week 1.0 ± 1.9 1.2 ± 1.7 − 0.2 (− 1.28 to p = 0.84 being 1. The agreement between the VAS and NRS seems
0.88) to vary across pain severity levels, and the pain ratings of
Overall 2.2 ± 2.2 2.2 ± 2.1 0.0 (− 1.22 to p = 0.81 both scales were reported to be not associated [44]. The
1.22)
NRS scores list descriptors of pain (such as no pain, mild,
*
Mann–Whitney test moderate, or severe) and may be translated into assigned

13

numbers [45]. Although this rating scale is not very sensi-
tive, it can be easy to understand by the participants. In
contrast, the VAS used in this study, with the anchor labels
“no sensitivity” and “severe sensitivity,” is very robust,
besides being the most common pain scale used in bleach-
ing studies [46, 47].
Also, in the present study, several tools (VITA Classi-
cal, VITA Bleached 3D-Master, and Easyshade spectropho-
tometer) and metrics (ΔSGU for each scale, ΔEab, ΔE00,
and ­WID) were used to measured color change, and they
need some explanations. Although the Easyshade spectro-
photometer is a more objective and precise tool to measure
color change when compared to VITA Classical and VITA
bleached 3D-Master [48, 49], the majority of clinicians do
not have access to this tool, especially due to its high cost.
Therefore, it is hard for clinicians to compare the results of
the present study with the results observed in daily practice.
Thus, the use of subjective scales could be justified. Also, as
VITA Classical scale had been used for a long time, the data
of the present study allows for comparison with data from
earlier studies [4, 14, 37–39]. Finally, although all color
measurements in the present study are in agreement, the use
of different tools and metrics allows a more comprehensive
methodology to evaluate the color change as observed in
several recently published clinical trials [3, 25, 26, 28, 32].
In conclusion, the lower degree of bleaching observed
when the bleaching gel was applied to the lingual surface
indicates that this technique should not be performed as a
first choice. However, in the case of patients with aesthetic
restorations or ceramic veneers, for whom the application
of the gel to the buccal surface is not possible, applying the
gel to the lingual surface could be a viable alternative that
produces satisfactory aesthetic results, and dentists should
adjust the time of use of the gel according to the desired
results.
Conclusion
Although at-home bleaching applied to the lingual surface
did not increase BS, it also did not achieve a similar color
change compared to at-home dental bleaching applied to the
buccal surface.
Acknowledgements The authors of thisstudy would like to thank
the Coordination for the Improvement of HigherEducation Person-
nel (CAPES), Ministry of Education, Brazil (Finance Code 001),
for the financial support tothe Graduate Program in Dentistry at the
Federal University of Amazonas (PPGOUFAM) and National Coun-
cil for Scientific andTechnological Development (CNPq) under grant
308286/2019-7. This studywas developed during the Visiting Professor
Scholarship of Prof. Dr. AlessandroD. Loguercio in the Federal Univer-
sity of Amazonas (Edital 019/2013 – FAPEAM).The authors also thank
FGM for the donation of the bleaching gels employed inthis study.
13
Clinical Oral Investigations
Declarations
Ethics approval The clinical investigation was approved (2.455.095) by
the scientific review committee and by the committee for the protection
of human participants of the State University of Ponta Grossa.
Informed consent All the participants gave their informed consent
prior to their inclusion in the study. Details that might disclose the
identity of the subjects under study were omitted. Informed consent
was obtained from all individual participants included in the study.
Conflict of interest The authors declare no competing interests.
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