Professional Documents
Culture Documents
139]
Review Article
ABSTRACT
The objective of this paper was to bring together and summarize the available information on the effects of different desensitizing
agents on bleaching treatments. Information from all scientific papers and reviews identified in the Institute for Scientific
Information Web of Science and PubMed using the search terms: Bleaching, whitening, brightening or color and desensitizing,
fluoride, potassium nitrate, or amorphous calcium phosphate was included in the data collected and synthesized to produce
the summary of findings and recommendations. The use of desensitizing agents in bleaching treatments may limit or control
sensitivity, promote remineralization, increase enamel microhardness, and enhance the efficacy of the bleaching treatment. The
use of desensitizing agents may exert a positive influence on the outcome of bleaching treatments.
Key words
Bleaching treatments, desensitizing agents, enamel microhardness, remineralization, sensitivity
DOI:
10.4103/2278-9626.134829 Figure1: Shade improvement after home bleaching treatment with 10%
carbamide peroxide
Kose reported that pretreatment with 5% potassium Haywood performed a study in which one group of
nitrate and 2% sodium fluoride reduced the duration of patients prebrushed with potassium nitrate toothpaste
sensitivity during bleaching treatmentthe placebo group for 2weeks before bleaching, while the other group of
had sensitivity on 35% of the bleaching days, while the patients prebrushed with fluoride toothpaste. The group
desensitizing agent group had sensitivity on 20% of the using the potassium nitrate toothpaste experienced less
bleaching days.[12] Browning investigated 10% carbamide sensitivity and more sensitivefree days than the fluoride
peroxide, containing potassium nitrate(3%) and sodium toothpaste group.[23]
fluoride(0.11%). This modified bleaching gel was found
to be safe and effective, with patients experiencing minor Basting compared the effectiveness and tooth sensitivity
sensitivity only.[13] with 10% and 20% carbamide peroxide home bleaching,
and office bleaching using 35% and 38% hydrogen
In other studies, potassium nitrate had no effect on peroxide, including potassium nitrate and fluoride.
tooth sensitivity associated with bleaching.[14] Kishore All bleaching treatments were effective in bleaching
found that 10% strontium chloride solution, 2% sodium teeth. Overall, 43% of the patients experienced mild
fluoride solution and 40% formalin solution significantly or moderate tooth sensitivity. The highest prevalence
reduced dentin hypersensitivity, whereas 5% potassium of sensitivity(71%) was found in patients who used
nitrate solution did not. [15] Gallo evaluated the use 20% carbamide peroxide home bleaching.[24] Only 15% of
of 30% carbamide peroxide containing 5% potassium patients experienced tooth sensitivity in the group using
nitrate. The addition of the potassium nitrate has little 38% hydrogen peroxide.[24]
effect on sensitivity, but the bleaching time was short
duration(1h a day for 10days).[16] Leonard suggested that applying 3% potassium nitrate
and 0.11% fluoride for 30 min before whitening may
One study reported that 20% carbamide peroxide reduce sensitivity for at risk patients.[25] Matis showed
containing 3% potassium nitrate and 0.11% ion fluoride that when patients experienced tooth sensitivity during
increased the microhardness of the substrate enamel.[17] bleaching treatment, they were instructed to place the
desensitizing gel(3% KNO3 and 0.11% fluoride) into
Tay evaluated 5% potassium nitrate and 2% sodium bleaching tray and wear it 4-5h through the night, by
fluoride use before inoffice bleaching. The desensitizing doing this tooth sensitivity was reduced.[26]
agent did not affect the bleaching efficacy, but reduced
tooth sensitivity. Few participants(47%) in the Miles found a reduction in bond strength in orthodontic
experimental group experienced sensitivity compared to bracket bonding after bleaching.[27] Ray concluded that
the control group(87%), and the severity of the sensitivity the use of a potassium oxalatebased desensitizing agent,
was significantly lower.[18] possibly in combination with 10% carbamide peroxide
limited the reduction in shear bond strength to a level
Gamma investigated inoffice bleaching using 35% above the recommended level for orthodontic bracket
hydrogen peroxide and 37% carbamide peroxide, bonding(5.9-7.8 MPa). Bleaching with 10% carbamide
combined with casein phosphopeptideamorphous peroxide containing a desensitizing agent was not
calcium phosphate(CPPACP), which largely prevented considered to be contraindicating before fixed orthodontic
surface roughening and reduction in hardness.[19] Reis appliance therapy.[28]
Ferreira studied the morphology of enamel treated with deposition of phosphate and calcium ions in exposed
35% hydrogen peroxide, followed by 1.23% acidulated dentinal tubules.[58]
fluoride gel. Changes in enamel morphology were greater
after the fluoride application. The changes included Borges investigated the effect of MI paste(GC Corporation,
porosities, depressions, and surface irregularities.[49] Tokyo, Japan), containing CPPACP and 22% carbamide
Martin evaluated the effect of fluoride on enamel exposed to peroxide. The MI paste did not affect the bleaching,
bleaching gels(16% carbamide peroxide or 35% hydrogen but reduced tooth sensitivity.[59] Grobler assessed the
peroxide). The application of 2% topical fluoride reduced whitening efficacy of 10% Nite White (Discus Dental,
the increase in the enamel surface roughness after Victoria, Australia) containing ACP, potassium nitrate
bleaching.[50] and fluoride over a 6months period. Nite White and ACP
demonstrated significant tooth whitening with relatively
Chuang showed that 0.37% fluoride in 10% carbamide little tooth sensitivity.[60]
peroxide reduced enamel demineralization and
maintained the microtensile bond strength, aiding Matis compared the effects of additions of potassium
any subsequent restorative procedure.[51] Chuang also nitrate and ACP to carbamide peroxide. The reduction
reported that 0.11% fluoridated 10% carbamide peroxide in sensitivity was similar. Subjects using the potassium
reduced microtensile bond strength, the bond strength nitrate modified gel had a greater bleaching effect than
was regained after 7days.[51] Another study reported those using the ACP gel.[61] Bayrak found that CPPACP
that fluoride treatment after bleaching did not reverse a significantly increased enamel microhardness following
reduction in enamelresin shear bond strengths.[52] bleaching with 38% hydrogen peroxide, while fluoride gel
had no effect on enamel microhardness.[62]
Marcelo showed the ultimate tensile strength of enamel
was not decreased after treatment of carbamideperoxide Remineralization induced by ACP was found to be much
containing fluoride or calcium.[53] more effective than that produced by potassium nitrate or
fluoride alone.[63] Giniger showed that ACP in whitening
gels could reduce tooth sensitivity by remineralization.[64]
The effect of fluoride on tooth sensitivity, however, remains
Another study reported that ACP caused ACP compounds
controversial. Armenio investigated the effect on tooth
to crystallize, forming hydroxyapatite.[65]
sensitivity of applying 1.23% fluoride gel in a bleaching
tray for 4min, following the use of 16% bleaching agent. It
Singh concluded that bleached enamel surfaces showed
was concluded that the fluoride treatment did not reduced
more color stability when treated with CPPACP. [66]
the occurrence of bleaching related tooth sensitivity,
Vasconcelos investigated bleaching with 7.5% hydrogen
however it decreased the intensity of the sensitivity.[54] If
peroxide and 16% carbamide peroxide in association with
the patient had sensitive teeth, the concomitant use of
a CPPACP paste(MI paste, GC Corporation). CPPACP
fluoride reduced tooth sensitivity and allowed patients to
did not affect tooth whitening efficacy. [67] Manton
continue their bleaching regimen.[54] Jorgensen reported suggested that Tooth Mousse(GC Corporation) might
that the application of fluoride had no benefit in the be applied concurrently with bleaching, and not reduce
management of bleaching related tooth sensitivity. bleaching effectiveness.[68] Giniger concluded that the gel
The use of a whitening solution with 0.11% fluoride containing ACP offered 10% better longterm whitening
resulted in 68% of the participants experiencing tooth efficacy. There were no adverse gingival or other negative
sensitivity. This percentage of participating patients effects observed.[57]
experiencing sensitivity was comparable to that found
in other studies, using carbamide peroxide without any Borges evaluated 10% and 16% carbamide peroxide
desensitizing agents.[55] modified by CPPACP. The CPPACP increased the
enamel microhardness without compromising whitening
Betke demonstrated fluoride varnish reduced dentine efficacy.[69] Khoroushi reported that CCPACP could
dehydration and decreased tooth sensitivity in bleaching compensate for any loss of flexural strength of the enamel
treatment. [56] Furthermore, mineral loss could be and dentine complex during bleaching.[70]
significantly reduced by topical fluoride application
following bleaching.[47]
VARNISHES
AMORPHOUS CALCIUM PHOSPHATE Ziebolz conducted a study on the effects of
VivaSens(Ivoclar Vivadent, NewYork, United States)
Ginger compared the effects of 16% carbamide peroxide on a painton bleaching agent(VivaStyle Paint On Plus,
with and without the addition of ACP. The addition of Ivoclar Vivadent). Similar color changes were observed
ACP significantly reduced sensitivity and enhanced for the control and VivaSens groups. Tooth sensitivity
the bleaching outcome. [57] ACP resulted in a rapid was lower in the Vivasens group; however, the difference
desensitizing effect through protein binding and the was not significant.[71]
whitening strips to a low peroxide and potassium nitrate bleaching carbamide peroxide gels. Caries Res 2003;37:939.
gel. Am J Dent 2002;15 Spec No:19A23. 41. AttinT, BetkeH, SchippanF, WiegandA. Potential of fluoridated
22. GroblerSR, MajeedA, HaywardR, RossouwRJ, MoolaMH, carbamide peroxide gels to support postbleaching enamel
van W KotzeTJ. Aclinical study of the effectiveness of two different rehardening. JDent 2007;35:7559.
10% carbamide peroxide bleaching products: A6month followup. 42. HellwigE, AttinT, KielbassaAM, SchallerHG. Fluoride uptake
Int J Dent 2011;2011:167525. in enamel after different tooth bleaching procedures. J Dent Res
23. HaywoodVB, CorderoR, WrightK, GendreauL, RuppR, KotlerM, 1995;74:4015.
etal. Brushing with a potassium nitrate dentifrice to reduce 43. AttinT, DumontB, BuchallaW. Fluoride uptake in caries, eroded
bleaching sensitivity. JClin Dent 2005;16:1722. and sound enamel after application of a 2000ppm fluoride solution.
24. BastingRT, AmaralFL, Frana FM, Flrio FM. Clinical comparative Br Dent J 2000;55:45562.
study of the effectiveness of and tooth sensitivity to 10% and 20% 44. ChenHP, ChangCH, LiuJK, ChuangSF, YangJY. Effect of fluoride
carbamide peroxide homeuse and 35% and 38% hydrogen peroxide containing bleaching agents on enamel surface properties. JDent
inoffice bleaching materials containing desensitizing agents. Oper 2008;36:71825.
Dent 2012;37:46473. 45. Paes LemeAF, TabchouryCP, ZeroDT, CuryJA. Effect of fluoridated
25. Leonard RH Jr, SmithLR, GarlandGE, CaplanDJ. Desensitizing dentifrice and acidulated phosphate fluoride application on early
agent efficacy during whitening in an atrisk population. JEsthet artificial carious lesions. Am J Dent 2003;16:915.
Restor Dent 2004;16:4955. 46. BurgmaierGM, SchulzeIM, AttinT. Fluoride uptake and
26. MatisBA, MousaHN, CochranMA, EckertGJ. Clinical evaluation development of artificial erosions in bleached and fluoridated enamel
of bleaching agents of different concentrations. Quintessence Int invitro. JOral Rehabil 2002;29:799804.
2000;31:30310. 47. Bizhang M, Seemann R, Duve G, Rmhild G, Altenburger JM,
27. MilesPG, PontierJP, BahiraeiD, CloseJ. The effect of carbamide JahnKR, etal. Demineralization effects of 2 bleaching procedures
peroxide bleach on the tensile bond strength of ceramic brackets: on enamel surfaces with and without posttreatment fluoride
An invitro study. Am J Orthod Dentofacial Orthop 1994;106:3715. application. Oper Dent 2006;31:7059.
28. RayS, LondheS, MitraR, ChopraSS. Are bleaching and desensitizing 48. Attin T, Albrecht K, Becker K, Hannig C, Wiegand A. Influence
agents contraindication for patients seeking orthodontic treatment? of carbamide peroxide on enamel fluoride uptake. J Dent
Orthodontics(Chic.) 2012;13:e1817. 2006;34:66875.
29. Smith LR, Leonard RH, Eagle JC, Murdock WC, Garland GE, 49. Ferreira SdaS, Arajo JL, MorhyON, TapetyCM, YoussefMN,
CaplanDJ. Efficacy of desensitizing gel in reducing tooth sensitivity Sobral MA. The effect of fluoride therapies on the morphology of
during whitening. JDent Res 2001;80:247. bleached human dental enamel. Microsc Res Tech 2011;74:5126.
30. BarrosMatoso F, de SouzaGabriel AE, FurtadoMessias DC, 50. MartinJM, de AlmeidaJB, RosaEA, SoaresP, TornoV, RachedRN,
de SousaNetoMD, AlfredoE. Microhardness of intracoronal dentin etal. Effect of fluoride therapies on the surface roughness of human
exposed to bleaching and fluoride treatment. Oral Surg Oral Med enamel exposed to bleaching agents. Quintessence Int 2010;41:718.
Oral Pathol Oral Radiol Endod 2011;112:e15. 51. Chuang SF, Chen HP, Chang CH, Liu JK. Effect of fluoridated
31. AttinT, KielbassaAM, SchwanenbergM, HellwigE. Effect of fluoride carbamide peroxide gels on enamel microtensile bond strength.
treatment on remineralization of bleached enamel. JOral Rehabil Eur J Oral Sci 2009;117:43541.
1997;24:2826. 52. MetzMJ, CochranMA, MatisBA, GonzalezC, PlattJA, PundMR.
32. BorgesAB, SamezimaLY, FonsecaLP, YuiKC, BorgesAL, TorresCR. Clinical evaluation of 15% carbamide peroxide on the surface
Influence of potentially remineralizing agents on bleached enamel microhardness and shear bond strength of human enamel. Oper
microhardness. Oper Dent 2009;34:5937. Dent 2007;32:42736.
33. BorgesAB, YuiKC, DAvilaTC, TakahashiCL, TorresCR, BorgesAL. 53. GianniniM, SilvaAP, CavalliV, Paes LemeAF. Effect of carbamide
Influence of remineralizing gels on bleached enamel microhardness peroxidebased bleaching agents containing fluoride or calcium on
in different time intervals. Oper Dent 2010;35:1806. tensile strength of human enamel. JAppl Oral Sci 2006;14:827.
34. da CostaJB, MazurRF. Effects of new formulas of bleaching gel 54. Armnio RV, Fitarelli F, Armnio MF, Demarco FF, Reis A,
and fluoride application on enamel microhardness: An invitro study. LoguercioAD. The effect of fluoride gel use on bleaching sensitivity:
Oper Dent 2007;32:58994. Adoubleblind randomized controlled clinical trial. JAm Dent Assoc
35. LewinsteinI, FuhrerN, ChuraruN, CardashH. Effect of different 2008;139:5927.
peroxide bleaching regimens and subsequent fluoridation on 55. JorgensenMG, CarrollWB. Incidence of tooth sensitivity after home
the hardness of human enamel and dentin. J Prosthet Dent whitening treatment. JAm Dent Assoc 2002;133:107682.
2004;92:33742. 56. BetkeH, KahlerE, ReitzA, HartmannG, LennonA, AttinT. Influence
36. de OliveiraR, Paes LemeAF, GianniniM. Effect of a carbamide of bleaching agents and desensitizing varnishes on the water content
peroxide bleaching gel containing calcium or fluoride on human of dentin. Oper Dent 2006;31:53642.
enamel surface microhardness. Braz Dent J 2005;16:1036. 57. Giniger M, Spaid M, MacDonald J, Felix H. A 180day clinical
37. TanizawaY. Reaction characteristics of a toothbleaching agent investigation of the tooth whitening efficacy of a bleaching gel with
containing H2O2 and NaF: In vitro study of crystal structure change added amorphous calcium phosphate. JClin Dent 2005;16:116.
in treated hydroxyapatite and chemical states of incorporated 58. Walsh LJ, Wang WS. Cakar A, Devani C, Tran KK, Hall A.
fluorine. JCosmet Sci 2005;56:12134. Effect of CPPACP versus potassium nitrate on cervical dentinal
38. CavalliV, RodriguesLK, PaesLemeAF, BrancalionML, ArrudaMA, hypersensitivity. JDent Res 2006;85(spec Iss A):Abstract 947.
BergerSB, etal. Effects of bleaching agents containing fluoride and 59. BorgesBC, de VasconselosAA, CunhaAG, PinheiroFH,
calcium on human enamel. Quintessence Int 2010;41:e15765. MachadoCT, dos SantosAJ. Preliminary clinical reports of a
39. LeandroGA, AttiaML, CavalliV, do RegoMA, LiporoniPC. novel nightguard tooth bleaching technique modified by casein
Effects of 10% carbamide peroxide treatment and sodium fluoride phosphopeptideamorphous calcium phosphate(CCPACP). Eur J
therapies on human enamel surface microhardness. Gen Dent Esthet Dent 2011;6:44653.
2008;56:2747. 60. GroblerSR, MajeedA, MoolaMH, RossouwRJ, van Wyk KotzeT. In vivo
40. AttinT, KocabiyikM, BuchallaW, HannigC, BeckerK. Susceptibility spectrophotometric assessment of the tooth whitening effectiveness of
of enamel surfaces to demineralization after application of fluoridated nite white 10% with amorphous calcium phosphate, potassium nitrate
and fluoride, over a 6month period. Open Dent J 2011;5:1823. 69. BorgesBC, BorgesJS, de MeloCD, PinheiroIV, SantosAJ, BrazR,
61. MatisBA, CochranMA, EckertGJ, MatisJI. In vivo study of two etal. Efficacy of a novel athome bleaching technique with carbamide
carbamide peroxide gels with different desensitizing agents. Oper peroxides modified by CPPACP and its effect on the microhardness
Dent 2007;32:54955. of bleached enamel. Oper Dent 2011;36:5218.
62. BayrakS, TuncES, SonmezIS, EgilmezT, OzmenB. Effects of 70. KhoroushiM, MazaheriH, ManoochehriA. Effect of CPPACP
casein phosphopeptideamorphous calcium phosphate(CPPACP) application on flexural strength of bleached enamel and dentin
application on enamel microhardness after bleaching. Am J Dent complex. Oper Dent 2011;36:3729.
2009;22:3936. 71. ZiebolzD, HannigC, AttinT. Influence of a desensitizing agent on
63. TschoppeP, NeumannK, MuellerJ, KielbassaAM. Effect of efficacy of a painton bleaching agent. Am J Dent 2008;21:7782.
fluoridated bleaching gels on the remineralization of predemineralized 72. HannigC, WeinholdHC, BeckerK, AttinT. Diffusion of peroxides
bovine enamel invitro. JDent 2009;37:15662. through dentine invitro with and without prior use of a desensitizing
64. GinigerM, MacdonaldJ, ZiembaS, FelixH. The clinical performance varnish. Clin Oral Investig 2011;15:8638.
of professionally dispensed bleaching gel with added amorphous 73. da Costa SoaresMU, Arajo NC, BorgesBC, Sales WdaS, SobralAP.
calcium phosphate. JAm Dent Assoc 2005;136:38392. Impact of remineralizing agents on enamel microhardness recovery
65. MathewM, TakagiS. Structures of biological minerals in dental after inoffice tooth bleaching therapies. Acta Odontol Scand
research. JRes Natl Inst Stand Technol 2001;106:103544. 2013;71:3438.
66. SinghRD, RamSM, ShettyO, ChandP, YadavR. Efficacy of casein 74. GjorgievskaE, NicholsonJW. Prevention of enamel demineralization
phosphopeptideamorphous calcium phosphate to prevent stain after tooth bleaching by bioactive glass incorporated into toothpaste.
absorption on freshly bleached enamel: An invitro study. JConserv Aust Dent J 2011;56:193200.
Dent 2010;13:769. 75. de OliveiraR, BastingRT, RodriguesJA, Rodrigues AL Jr, SerraMC.
67. de VasconcelosAA, CunhaAG, BorgesBC, MachadoCT, dos Effects of a carbamide peroxide agent and desensitizing dentifrices
SantosAJ. Tooth whitening with hydrogen/carbamide peroxides on enamel microhardness. Am J Dent 2003;16:426.
in association with a CPPACP paste at different proportions. Aust
Dent J 2012;57:2139.
68. Manton DJ, Bhide R, Hopcraft MS, Reynolds EC. Effect of ozone How to cite this article: Po LH, Wilson NW. Effects of different desensitizing
agents on bleaching treatments. Eur J Gen Dent 2014;3:93-9.
and Tooth Mousse on the efficacy of peroxide bleaching. Aust Dent
Source of Support: Nil, Conflict of Interest: None declared.
J 2008;53:12832.
Announcement
Android App
A free application to browse and search the journals content is now available for Android based
mobiles and devices. The application provides Table of Contents of the latest issues, which
are stored on the device for future offline browsing. Internet connection is required to access the
back issues and search facility. The application is compatible with all the versions of Android. The
application can be downloaded from https://market.android.com/details?id=comm.app.medknow.
For suggestions and comments do write back to us.