Clin Oral Invest (2014) 18:839845

DOI 10.1007/s00784-013-1055-7

ORIGINAL ARTICLE

Effectiveness of a desensitizing agent before in-office tooth

bleaching in restored teeth
Elize Bonaf & Alessandro Dourado Loguercio &
Alessandra Reis & Stella Kossatz

Received: 11 February 2013 / Accepted: 15 July 2013 / Published online: 20 August 2013
# Springer-Verlag Berlin Heidelberg 2013

Abstract
Objectives The aim of this clinical trial was to evaluate the
effectiveness and tooth sensitivity associated with bleaching
in patients with composite restorations in anterior teeth after
the application of a desensitizing agent.
Material and methods Bleaching was performed with 35 %
hydrogen peroxide gel in 30 patients with composite restorations in anterior teeth, divided according to the prior application of a desensitizing agent (De), or a placebo (Pl), on
maxillary superior teeth. Color was recorded at baseline,
1 week after each session and 6 months after treatment. The
experience of tooth sensitivity (TS) was recorded on an NRS
(04) during bleaching and 24 h after each session. Bleaching
effectiveness was evaluated by one-way ANOVA and Tukey's
tests (=0.05). The percentage of TS was evaluated by Fisher's exact test. For each treatment, periods were compared
using the Wilcoxon signed-rank test (=0.05), and at each
period, treatments were compared using MannWhitney U
test.
Results Both groups showed similar tooth color enhancement
and color stability after 6 months (p<0.05). No significant
difference in prevalence of sensitivity was detected between
groups (p<0.001). Higher TS intensity (median [first/third
quartiles]) was observed for Pl (1.5 [1/1.75]) compared with
De (0.5 [0/1]) during treatment (p<0.05).
Conclusions The use of a desensitizing gel (5 % potassium
nitrate, 2 % sodium fluoride) before tooth bleaching in patients
with composite restorations did not reduce the prevalence of
E. Bonaf : A. D. Loguercio : A. Reis : S. Kossatz
School of Dentistry, State University of Ponta Grossa, Ponta Grossa,
Paran, Brazil
E. Bonaf (*)
Programa de Ps-Graduao Stricto Sensu da UEPG, Departamento
de Odontologia, Campus de Uvaranas - Bloco M, Av. General Carlos
Cavalcanti 4748 - Uvaranas, 84030-900 Ponta Grossa, PR, Brazil
e-mail: elize_bonafe@msn.com

tooth sensitivity, but reduced the intensity of TS during

bleaching.
Clinical relevance Although the use of a desensitizing agent
before bleaching, in patients with composite resin restorations,
did not reduce the prevalence of TS, a reduction of the TS
intensity during the protocol was observed without jeopardizing the whitening outcome.
Keywords Desensitizing agent . Tooth bleaching . Hydrogen
peroxide . Tooth sensitivity

Introduction
At-home and in-office tooth bleaching treatment for tooth
discoloration are being used increasingly [1], with the inoffice option becoming more widely accepted because of the
intolerance of some patients to the use of the trays in addition
to their desire to achieve immediate results [2].
In spite of the good clinical results shown when a high
concentration (2035 %) of hydrogen peroxide (HP) is used in
more than one in-office bleaching session, clinical studies
have observed that there was high prevalence of tooth sensitivity related to this treatment modality (up to 87 %) [36].
This adverse effect is usually considered temporary and mild.
However, occasionally, it can produce considerable discomfort to the patient [7, 8].
The bleaching agent HP increases enamel permeability,
diffuses through dentin [9], and penetrates into the pulp chamber [10, 11]. The sensitivity associated with dental bleaching
may result from bleaching agents penetrating into the pulp
chamber leading to the activation of nociceptive sensors [12]
and transient inflammatory reactions [13].
In the majority of clinical studies, one of the inclusion
criteria is that patients must have sound teeth in anterior
maxilla [35, 14, 15], however, in general practice, the presence of composite restorations in anterior teeth is routinely

840

found in the clinical situation. Nevertheless, few studies have

included patients with restorations in clinical studies of inoffice bleaching [1618] which allows little information about
the efficiency of treatment or other peculiarities of this situation.
A higher level of sensitivity is expected when patients with
restored anterior teeth are submitted to the bleaching procedure, in comparison with patients with only sound anterior
teeth, because in vitro evaluations have shown that there is
greater penetration of bleaching agents into the pulp chamber
of restored teeth [1921].
There are several recommendations for reducing bleaching
sensitivity caused by tooth bleaching in sound teeth, such as
the administration of analgesics [22], decreased concentration
of the peroxide gel, and the application of desensitizing agents
[4, 5, 7, 14, 2326]. Among the desensitizing agents commonly used, the most successful therapy for decreasing the
sensitivity related to the bleaching procedure is to use a
desensitizer agent based on fluoride and potassium nitrate
before [5, 14, 26, 27], during [24], and after the bleaching
procedures [28] without reducing the effectiveness of treatment.
However, the benefits of this desensitizing protocol have
only been determined in sound teeth. Whether or not this
procedure is effective in patients with composite restorations
in anterior teeth has not been evaluated yet. Therefore, the aim
of this study was to evaluate if the prior application of a
desensitizer gel could reduce the prevalence and intensity of
the tooth sensitivity in patients with composite restorations in
anterior teeth. The bleaching effectiveness and the stability of
the bleaching outcome after 6 months were also investigated.

Materials and methods

This clinical investigation was approved under protocol number 12/2011 by the Scientific Review Committee and by the
Committee for the Protection of Human Beings of the university. Based on preestablished criteria, 30 volunteers were
selected for this study. Two weeks before the bleaching procedures, all the volunteers received dental screening and prophylaxis with pumice and water slurry in a rubber cup. They
also signed a term of free and informed consent.
Inclusion and exclusion criteriai Participants included in this
clinical trial were between 18 and 35 years old. A total of 64
participants were examined to check whether they met the
inclusion and exclusion criteria (Fig. 1). The participants were
required to have central incisors of shade A2 or darker, as
judged by comparison with a value-oriented shade guide,
(Vita Lumin, Vita Zahnfabrik, Bad Sckingen, Germany)
and to have at least one composite restoration in the central
incisor (and a maximum of four in other anterior teeth). These
restorations were not to involve more than 25 % of the facial
surface of the anterior teeth [18] and were to be judged as

Clin Oral Invest (2014) 18:839845

satisfactory (acceptable esthetically and functionally) according

to FDI criteria [29]. The following subjects were excluded from
the study, since they would not be suitable for a cosmetic study
such as bleaching: those who had undergone tooth-whitening
procedures, smokers, pregnant/lactating women; those with
severe internal tooth discoloration or endodontic treatment in
anterior teeth; and those taking any kind of medicine, with
bruxism habits, recession, dentin exposure, active caries lesions,
or reporting tooth sensitivity (TS) to cold drinks.
Sample size calculation With a 90 % confidence interval (CI),
the number of subjects required to detect an absolute risk of
TS was around 80 % for both groups [3, 4] with a total width
of the confidence interval of 0.35, being 14 participants per
group [30]. A total of 15 participants were selected for each
group in order to compensate for possible dropouts.
Study groups Participants who met the inclusion criteria were
randomly divided into the experimental (desensitizing (De))
or control (placebo (Pl)) group. At the first appointment, the
order of treatment type (De or Pl) was randomized by flipping
a coin for each patient's initial bleaching and the opposite
treatment was chosen for the second appointment. Neither
the patients nor the evaluators knew the group to which the
patients were assigned. The desensitizing and placebo gels
were given to the clinicians in unmarked syringes. The syringes were marked only with numbered codes that neither the
clinicians nor the patients could identify. The desensitizing
and placebo gels had the same basic composition (2 % deionized water, glycerine, thickening, and neutralizing agent),
viscosity, and pH (6.7). The unique difference is the active
ingredients. The desensitizing gel used contains 5 % potassium nitrate and 2 % sodium fluoride (Desensibilize KF 2 %,
FGM Dental Products, Joinville, SC, Brazil), and these ingredients were not presented in the placebo gel.
Study intervention Before the in-office bleaching, a desensitizing (Desensibilize KF 2 %, FGM) or placebo gel was
applied on the buccal surfaces of the anterior maxillary teeth.
The product was left undisturbed for 10 min. Then, with a
rubber cup mounted in a slow-speed handpiece, the product
was scrubbed on each surface for additional 20 s, as specified
by the manufacturer. The teeth were washed and dried and then
the gingival tissue of the teeth to be bleached was isolated using
a light-polymerized resin dam (Top Dam, FGM). HP gel, 35 %
(Whiteness HP Maxx, FGM) was used in three 15-min applications for both groups according to the manufacturer's directions. The in-office bleaching agent was refreshed every 15 min
during the 45-min application period. Two sessions with a 1week interval between them were performed.
Shade evaluation Shade evaluation was recorded using two
methods: a subjective evaluation using a shade guide (Vita

Clin Oral Invest (2014) 18:839845

841

Fig. 1 Flow diagram of the

clinical trial

Assessed for eligibility (n=64)

Enrollment
Excluded (n=34)
Central incisors lighter than A2
(n=17)
Tooth sensitivity to cold drinks
(n=10)
Endodontically treated Maxillary
anterior teeth (n=5)
Other reasons (n=2)

Randomized (n=30)

Allocation
Allocated to group De (n=15)
Received allocated intervention (n=15)

Allocated to group Pl (n=15)

Received allocated intervention (n=15)

Follow up
Lost to follow-up (n=0)
Discontinued intervention (n=0)

Lost to follow-up (n=0)

Discontinued intervention (n=0)
Analysis

Analyzed (n=15)

Lumin, Vita Zahnfabrik, Bad Sckingen, Germany) and an

objective evaluation using the spectrophotometer (Easyshade,
Vident, Brea, CA, USA). Color was evaluated with teeth in a
completely hydrated condition at baseline, 1 week and 6 months
after the bleaching protocol. Color was not evaluated soon after
each bleaching session in order to avoid the influence of tooth
demineralization [31] and dehydration that occurs simultaneously with the whitening effect on the final color outcome
[3234].
For the subjective examination, the 16 tabs of the shade
guide were arranged from the highest (B1) to the lowest (C4)
value, making the color A2 number 5, for example. Although this scale is not linear in the truest sense, the changes
were treated as though they represented a continuous and
approximately linear ranking for the purpose of analysis.
The measurement area of interest for shade matching was
the middle third of the facial surface of the anterior central
incisor. For calibration purposes, five patients, who were not
included in the sample because they were used in the pilot
study, participated in the training phase of this study. The
two examiners, blinded to the allocation assignment, scheduled these patients for bleaching and evaluated their teeth
against the shade guide. The two examiners were required to
have an agreement of at least 85 (weighted Kappa statistic)
before beginning the study evaluation. If disagreements
arose during evaluation, they were encouraged to reach a
consensus.

Analyzed (n=15)

For the objective evaluation, the method used by Marson

et al. [3] was followed. A preliminary impression of the maxillary arch was made using dense silicone Adsil (Vigodent S/A
Indstria e Comrcio, Rio de Janeiro, RJ, Brazil), which served
as a standard color measurement guide for the spectrophotometer. A window was created on the labial surface of the silicone
guide in order to evaluate the central incisor. The window was
made using a metal device with well-formed borders, with a
radius of 3 mm. The measurement was taken out in all 30
patients using Vita Easyshade (Easyshade, Vident, Brea, CA,
USA) at the same time as the assessment made in the subjective
evaluation. In the restored teeth, care was taken to perform the
measurements only on the tooth surface. The shade was determined using the parameters of the Easyshade device, which
indicated the following values: 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
redgreen axis, and b* is the measurement along the yellow
blue axis. The color comparison before and after 1 week and
6 months of treatment was given by the differences between the
two colors (E), which was calculated using the formula:
E=[(L*)2 +(a*)2 +(b*)2]1/2 [35].
Tooth sensitivity evaluation The participants recorded their
perception of TS during the bleaching procedure on a daily basis
up to 7 days after each bleaching session. A five-point verbal
rating scale (0=none, 1=mild, 2=moderate, 3=considerable,

842

and 4=severe) [5, 36] was used in this study. The values
were arranged into two categories: percentage of patients
that reported TS at least once during treatment (absolute
risk of TS) and overall TS intensity during and up to 24 h
after each bleaching session. The participants were also
instructed to identify the painful teeth every time they
experienced TS.
Statistical analysis The analysis followed the intention-totreat protocol and involved all participants who were randomly assigned [37]. The statistician was blinded to the study
groups.
The primary outcome, absolute risk of TS, was compared
by means of Fisher's exact test. Statistical analyses of TS
intensity, comparing the two groups in each of the assessment
points, were performed using the MannWhitney U test. As
two bleaching sessions were performed, the median score at
each assessment point was considered for statistical analysis.
Comparisons between times within each group were performed using the Wilcoxon signed-rank test. The proportion
of patients from the two groups who reported TS at least once
in the central incisors, lateral incisors, canines, and premolars
was calculated and compared by means of the chi-square test.
In this case, only restored teeth were considered.
For the subjective color evaluation, the mean and standard
deviations of shade guide units (SGU) at baseline, 1 week
after and 6 months after bleaching were compared by means
of two-way repeated measures ANOVA (groups vs. assessment time) and Tukey's test. The data from SGU and E of
the two groups were submitted to two-way repeated measures
ANOVA. A post hoc analysis (Tukey's test) was used to make
pairwise comparisons. In all statistical tests, the significance
level was set at =0.05.

Results
A total of 64 participants in an age range from 18 to 35 years
were evaluated to select 30 participants who met the inclusion
criteria. Reasons for exclusion of participants are shown in
Fig. 1. The mean age (years) of the participants in this study
was similar between the two groups (De=24.84.1 and
Pl=24.84.4). Sixty four percent of the participants were
women, 10 in the desensitizer group and 11 in the placebo
group.
The two-way ANOVA for the SGU data showed that only
the main factor assessment time was statistically significant
(ANOVA test; p<0.001). A higher degree of bleaching was
obtained after 2 weeks of treatment, and this result was stable
after 6 months for both groups (Table 1). The SGU and E
values showed a similar trend. Neither the main factors nor the
cross product interaction were statistically significant (ANOVA
test, p>0.05). This means that a degree of bleaching of

Clin Oral Invest (2014) 18:839845

approximately four SGU was detected for both groups, and this
was stable after 6 months (Table 2).
Almost all participants in this study reported TS at least
once during treatment, and thus the absolute risk of TS was
100 % for the control group (95 % CI, 79.6100 %) and 93 %
for the experimental group (95 % CI, 70.198.8 %) for the two
groups (Fisher's exact test, p=1.0). With regard to the
intensity of TS (Table 3), participants in the experimental
group reported lower intensity during bleaching than those in
the placebo group (MannWhitney U test, p=0.032).
For all patients included in this clinical trial, the teeth with
most complaints of TS were the lateral incisors (73.3 %),
which differed statistically from the canines and premolars
(chi-square test, p<0.05) but were similar to the central
incisors (Table 4).

Discussion
As has been previously reported in several studies [5, 14, 24],
the results of the present study indicate that the application of a
2 % sodium fluoride and 5 % potassium nitrate desensitizing
agent does not interfere with the bleaching efficacy of 35 %
hydrogen peroxide, as it does not seem to affect the transenamel and transdentinal diffusion of hydrogen peroxide due
to the low molecular weight of this oxidizing molecule [14,
24]. Both groups demonstrated similar and significant tooth
color enhancement when compared with the baseline values,
with a variation of four SGU, which is in agreement with a
previous study [6].
With respect to color stability, 6 months after bleaching, no
significant differences were detected between the groups and
there was also no significant color rebound, as was expected,
in agreement with other studies [3, 6, 38], considering that inoffice bleaching seems to achieve satisfactory results when
more than one session is performed [39]. It's worth mentioning that laboratory studies have shown that there was no
change in or compromise of restorations due to the use of
high-concentration peroxides when the factor time for applying the bleaching agent was respected [40, 41]. Future
Table 1 Means and standard deviations of shade guide units (Vita
Classical shade guide) at different assessment points for the two treatment
groups

Baseline
1 week after bleaching
6 months after bleaching

Placebo

Desensitizer

5.91.1aA
1.80.7aB
1.90.6aB

6.01.1aA
1.50.6aB
1.70.7aB

The same lowercase letters indicate statistically similar means within

rows. The same uppercase letters indicate statistically similar means
within columns (Tukey's test, =0.05)

Clin Oral Invest (2014) 18:839845

843

Table 2 Means and standard deviations of SGU (subjective evaluation) and E (objective evaluation) at different assessment points for the
two treatment groups
SGU
Placebo

E
Desensitizer Placebo

Table 4 Number of patients who reported tooth sensitivity at least once

in the different tooth types
Tooth type

Number of patients of each

groupa

Overall proportion
(95 % CI)

Desensitizer
Control Experimental Overall

Baseline vs. 1 week

Baseline vs.
6 months

4.10.9a 4.40.9a
4.00.9a 4.40.9a

4.71.1A 4.20.8A
4.10.7A 4.21.3A

Means indicated by the same lowercase letters indicate statistically similar

means for SGU and means indicated by the same uppercase letters
indicate statistically similar means for E (Tukey's test, =0.05)

investigations into the color stability of cosmetic restorations

in patients would be interesting, in order to assess the longevity of bleaching procedures under this circumstance over the
course of time.
Bleaching occurs due to the action of hydrogen peroxides
that permeate through the enamel and dentin [10, 41, 42]. This
permeation promotes the release and expression of inflammatory mediators in the pulp [13] and can cause damage to the
pulp cells [44]. Dental pulp is innervated with sensory afferents with conduction velocities in the A, A, and C-fiber
range [45], and the pain sensations result from natural and
electrical stimuli that can activate these nerves.
In addition, the release of ATP, substance-P (a nerve released vasoactive peptide), and prostaglandins would excite or
sensitize pulpal nociceptors promoting sensitivity to bleaching
[13, 46]. It may explain why bleaching sensitivity is a common adverse effect of all tooth whitening techniques [5, 7, 14,
2326].
According to the previous literature, a high prevalence of
tooth sensitivity (TS) is expected when in-office bleaching is
applied [35, 17]. This was also shown in the present study,
when almost all the patients experienced sensitivity at least
one time during the bleaching treatment. However, it was
expected that the use of desensitizer would decrease the prevalence of sensitivity, as was shown in the studies of Tay et al.
[14] and Reis et al. [5]. However, this did not occur in the

Table 3 Median and interquartiles ranges of tooth sensitivity reported by

patients at different assessment times for the two treatment groups

During bleaching
Up to 24-h postbleaching

Placebo

Desensitizer

1.5 (1/1.75)aA
2 (0/2)aA

0.5 (0/1)aB
1 (0.25/1)aA

At each treatment, the two periods were compared by means of Wilcoxon

signed-rank test (=0.05) and differences are represented by different
lowercase letters. For each period, the treatments were compared by
means of MannWhitney U test and the differences are represented
by different uppercase letters

Central incisors 8
Lateral incisors 11
Canines
4
Premolars
0

7
11
1
0

15
22
5
0

50.0 (33.266.9)
73.3 (55.685.8)
16.7 (7.333.6)
0 (00.11)

A
A
B
C

Proportions indicated by the same uppercase letters are statistically

similar (chi-square test, =0.05)

present study since there was similar prevalence of sensitivity

among the patients of the placebo and desensitizer groups.
As demonstrated in laboratory studies, restored teeth are
more permeable to hydrogen peroxide (HP) when compared
with sound teeth, and this permeability can be up to five times
higher [19, 20] because the adhesive interfaces in the restored
teeth may work as fast pathways for HP to reach the pulp and
because pulp cells may not be capable of producing enough
peroxidases, catalases [42], and oxygenases [47] to protect the
pulp from the immediate damage caused by HP. Therefore,
this high amount of HP impairs the desensitizer ability to
decrease the prevalence of TS, particularly since the prevalence of TS observed was high for both groups. Moreover, in
the inclusion criteria of Tay's and Reis's studies [5, 14], only
patients with sound teeth were accepted, and this could perhaps explain the difference between the present results and
those of the above-mentioned studies.
On the other hand, the desensitizer agent was effective in
decreasing the intensity of TS when a desensitizing agent
based on 2 % sodium fluoride and 5 % potassium nitrate
was used. The primary mechanism of action of sodium fluoride is associated with obstruction of the tubules, which reduces the possibility of the bleaching materials being able to
diffuse through the dentin [48]. However, potassium nitrate
has different action mechanism; although it is not associated
with decreasing dentin permeability, as it occurs with the use
of fluorides, it has been suggested that potassium nitrate
diffuses through the tubules and reaches the nerve endings,
prevents nerve stimulation, and blocks the transmission of
pain [4951].
It has been shown that the amplitudes of A, A, and Cfiber range components of isolated nerves were attenuated
when extracellular K+ was raised. Potassium ions applied to
outer dentin diffuse along the dentinal tubules to achieve a K+
of at least 8 mmol/L to inactivate intradental nerves in the
peripheral pulp at the pulpal ends of dentinal tubules and has
currently been used as a desensitizing agent associated with
bleaching [52]. In the results of the present study, lower

844

sensitivity was observed in the desensitizer group in comparison with the placebo group.
Due to action mechanism of potassium nitrate, it could be
speculated that although restored teeth are more susceptible to
penetration of the whitening agent, they also appeared to be
more permeable to the permeation of potassium nitrate. This
could perhaps explain lower intensity of sensitivity observed
in the desensitizer group, and this would confirm the satisfactory results obtained when it has been used as a desensitizing
agent associated with bleaching [5, 14, 27, 50].
Finally, we should point out an important study limitation.
Although the application of desensitizing agent reduced the
intensity of the TS in patients with composite resin restorations, this product cannot prevent the reversible histological
changes [43, 52] produced by the hydrogen peroxide. In this
context, it would be interesting to conduct investigations to
evaluate the use of different drugs capable to reduce the
oxidative stress in cells caused by the hydrogen peroxide such
as antioxidants, corticosteroids, or selective anti-inflammatory.

Conclusions
Although the application of desensitizer did not reduce the
prevalence of TS in patients with composite restorations, the
intensity of sensitivity was significantly reduced during inoffice bleaching which suggests that this protocol can minimize this common adverse effect. The application of desensitizer prior to bleaching did not affect the whitening outcome,
which was stable after 6 months of clinical evaluation.

Conflict of interest The authors declare that they have no conflict of

interests.

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