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Review Article

Effects of different desensitizing agents on bleaching treatments

Lam Hoi Po, Nairn Wilson1 Address for correspondence:


Dr.Lam Hoi Po,
Private Practitioner, Hong Kong, China, Department of Dentistry, Kings College London,
1
Shop 302, Yau Lai Shopping Centre,
Dental Institute, London, UK Yau Lai Estate, Yau Tong, Kowloon,
Hong Kong, China.
Email:donnyhplam@yahoo.com.hk

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

INTRODUCTION may cause changes in the surface of enamel also,


including the formation of porosities, pitting and areas
Bleaching is widely used and accepted as means to lighten of erosion, and decalcification of enamel prisms, possibly
teeth [Figure 1].[1] Bleaching materials include different together with alterations in surface topography.[5] The
concentrations of hydrogen peroxide. Sideeffects are application of both carbamide peroxide and hydrogen
associated with bleaching treatments. These include peroxide to teeth may reduce the microhardness of
tooth sensitivity, changes to the tooth structure and enamel.[6]
effects on bonding.
Bleaching agents may cause chemical softening, and
Tooth sensitivity is a common sideeffect and it occurs reduce the durability of resin composite restorations.[7]
as generalized hypersensitivity to cold stimuli or as Bleaching prior to the placement of restorations of resin
spontaneous sharp, short duration pain, limited to one composites may reduce adhesive and resin to enamel
or more teeth. Such sensitivity is usually temporary. bond strengths.[8]
It typically occurs early in the treatment and decrease
as treatment proceeds.[2] Sensitivity associated with
bleaching may be so severe that a significant minority
of patients(<14%) may be unable to complete their
bleaching treatment.[3]

The application of carbamide peroxide, as required for


dental bleaching, may reduce the calcium, phosphate,
and fluoride content of enamel.[4] Carbamide peroxide

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DOI:
10.4103/2278-9626.134829 Figure1: Shade improvement after home bleaching treatment with 10%
carbamide peroxide

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Po and Wilson: Effects of different desensitizing agents on bleaching treatments

POTASSIUM NITRATE assessed tooth sensitivity following the application


of 5% potassium nitrate and 2% sodium fluoride prior
Tam compared the effects of 10% carbamide peroxide to lightactivated bleaching. Less severe sensitivity was
with and without the addition of potassium nitrate and experienced by 80% of those in the experimental group.[20]
fluoride. There was no difference in the bleaching effect
of the two gels; however, the sensitivity associated with Gerlach compared whitening strips(6% hydrogen peroxide)
the use of the modified gel was significantly lower than with 5% carbamide peroxide, including 5% potassium
that experienced with the unmodified gel.[9] Browning nitrate, applied in a custom tray. The whitening strips
showed that the addition of 0.5% potassium nitrate to group displayed greater tooth whitening, and less tooth
10% carbamide peroxide reduced postoperative sensitivity sensitivity(13% subjects) compared to the custom tray
more than the addition of 3% potassium nitrate, without group(22% subjects).[21]
reducing the bleaching effect.[10] Haywood showed that
the addition of 5% potassium nitrate to bleaching gel Grobler compared two different 10% carbamide peroxide
applied in a bleaching tray was effective in reducing tooth bleaching products. One contains potassium nitrate
sensitivity.[11] If tooth sensitivity occurs, applying 5% and sodium fluoride, and the other contains potassium
potassium nitrate in a bleaching trays for 10-30min, may nitrate, ACP and fluoride. The patients using bleaching
be found to reduce sensitivity in>90% patients, allowing gel containing ACP experienced more relapse of color
many patients to complete their bleaching regime.[11] over a 6months period.[22]

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]

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Po and Wilson: Effects of different desensitizing agents on bleaching treatments

UltraEZ(Ultradent Products Inc., South Jordan, Utah) peroxide.[39]


contains 3% potassium nitrate and 0.11% fluoride.
Smith concluded that the use of UltraEZ before Attin found that 0.5% fluoridated carbamide peroxide
bleaching reduced tooth sensitivity in patients, even gel with pH7.0, reduced surface softening compared
those with preexisting sensitivity. UltraEZ was not to unfluoridated bleaching gel. Fluoride therapy during
found to have a statistically significant effect in reducing supervised bleaching was advised.[40] Attin reported also that
tooth sensitivity in patients representative of the general 10% carbamide peroxide, fluoridated with 0.5% fluoride,
population.[29] facilitated rehardening of bleached enamel faster
than unfluoridated gels.[41] Hellwig found that fluoride
FLUORIDE concentration decreased from the enamel surface down
to the enameldentinal junction in bleached enamel. The
Felipe reported that 5% sodium fluoride varnish highest fluoride concentration was found on the enamel
reestablished the surface microhardness of bleached surface, following high dosed fluoride application.[42]
dentin.[30] Attin reported that the application of either
2.23% fluoride varnish or 0.25% sodium fluoride Remineralization of bleached enamel was accelerated
significantly reduced loss of surface hardness loss in by the application of sodium fluoride. Fluoride uptake
bleached enamel.[31] by demineralized enamel is more than normal enamel.
Mineral crystals containing fluoride were precipitated
Borges reported that the addition of fluoride and within the demineralized layer.[35]Professional application
calcium to 35% hydrogen peroxide increased the of 1.23% APF gel and the use of sodium fluoride
microhardness of bleached enamel.[32] Borges reported mouthwash(0.02% or 0.5%) were recommended after
also that fluoride gel, and a combination of calcium and bleaching to aid enamel remineralization.[37] Attin showed
fluoride gel, significantly increased the microhardness that fluoride facilitated remineralization of enamel
of enamel bleached with 35% hydrogen peroxide.[33] In a softened by bleaching.[31]Attin reported that pretreatment
further study in which extracted molars were bleached of enamel with carbamide peroxide, before fluoride
with 10% carbamide peroxide, enamel microhardness application, did not induce higher uptake of fluoride,
was reduced. Two weeks later, following fluoride nor increased erosion resistance.[43]
treatment, all the bleached teeth showed a significant
increase in enamel microhardness.[34]
Chen reported that fluoridated bleaching gel resulted in
less marked demineralization changes, without affecting
Lewinstein reported that 0.05% fluoride restored the knoop whitening efficiency.[44] The application of 0.05% fluoride
hardness of enamel after inoffice bleaching(35% hydrogen
following bleaching restored the hardness of softened
peroxide and 35% carbamide peroxide) and home
dental tissues. Fluoride forms a calcium fluoride layer on
bleaching(10% and 15% carbamide peroxide). [35]
the enamel surface, inhibiting further demineralization.[45]
Basting showed no difference in the change in enamel
Acidulated fluoride gel results in more fluoride deposition
microhardness after treatment with 35% hydrogen
in bleached enamel than neutral gel. Frequent use of low
peroxide photo activated using diode laser with or without
concentration fluoride gel during bleaching may benefit
acidulated phosphate fluoride(APF).[17]
patients with a high risk of demineralization.[43] A study,
which evaluated the effects of fluoride after bleaching with
Costa studied the knoop microhardness of bleached
10% carbamide peroxide, found that enamel did not have an
enameltreated with 1.23% APF. Fluoridated
increased resistance to demineralization.[46] Attin reported
10% carbamideperoxide enabled rehardening of
that both fluoridated and nonfluoridated 10% carbamide
bleached enamel faster than unfluoridated gels. [34]
On the contrary, Oliveira reported that calcium and peroxide gels caused enamel more susceptible to
fluoride in bleaching gels did not restore the microhardness demineralization when neutral or acidic.[40]Bizhang showed
of the surface enamel.[36] that application of fluoride following bleaching reduced the
demineralization of enamel.[47]
Xray photoelectron spectroscopy investigations showed
that sodium fluoride in hydrogen peroxide gel induced Burgmaier reported that pretreatment with 2000ppm
the formation of fluoridated hydroxyapatite and calcium sodium fluoride before bleaching did not improve erosive
fluoride crystals on the tooth surface, aiding enamel resistance; bleaching reduced the fluoride concentration
remineralization.[37] Cavalli concluded that mineral loss in enamel despite the fluoride application. [46]Attin
was minimized by the addition of fluoride and calcium concluded that treatment with carbamide peroxide and
to 10% carbamide peroxide.[38] Leandro showed that amine fluoride caused less fluoride uptake in enamel
both the professional application of sodium fluoride and than amine fluoride alone. Carbamide peroxide can
the selfadministration of sodium fluoride mouthwash influence enamel fluoride uptake.[48] Burgmaier reported
remineralized enamel bleached using 10% carbamide that fluoride treatment could not compensate for the loss
of fluoride from enamel during bleaching.[46]

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Po and Wilson: Effects of different desensitizing agents on bleaching treatments

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]

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Po and Wilson: Effects of different desensitizing agents on bleaching treatments

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Source of Support: Nil, Conflict of Interest: None declared.
J 2008;53:12832.

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