Ó

Operative Dentistry, 0000, 00-0, 000-000

Effectiveness of Dental Bleaching

With 37.5% and 6%
Hydrogen Peroxide and
Its Effect on Quality of Life
C Bersezio  J Estay  G Jorquera  M Peña  C Araya  P Angel  E Fernández

Clinical Relevance
A gel with a low concentration of hydrogen peroxide (6%) achieves effective whitening with
a low occurrence and intensity of sensitivity. It also generates a positive effect on
psychosocial impact and esthetic self-perception among patients.

SUMMARY esthetics generated by extracoronal tooth

Objective: This study investigated whether it whitening.
is possible to achieve equally satisfactory Methods and Materials: A prospective, double-
results between 37.5% hydrogen peroxide blind, randomized clinical trial was carried
(HP) gel and 6% HP gel. We also assessed the out. A total of 33 patients were selected from
psychosocial impact and self-perception of the clinic of the Faculty of Dentistry at the
Cristian Bersezio, Department of Restorative Dentistry, University of Chile. The patients included men
Operative Dentistry, University of Chile, Santiago, Chile and women over 18 years old without prior
and Universidad Andres Bello, Santiago, Chile tooth whitening treatments, tooth decay, or
Juan Estay, Department of Restorative Dentistry, Operative restorations of the maxillary anterior teeth.
Dentistry, University of Chile, Santiago, Chile The patients had tooth colors of A3 or less
Gilbert Jorquera, Department of Prosthodontics, College of according to the Vita Classical scale, which
Dentistry, Universidad de Los Andes, Santiago, Chile was determined with a Vita Easy Shade spec-
Manuel Peña, Departament of Restorative Dentistry, Univer- trophotometer. The study was carried out with
sity of Chile Dental School, Santiago, Chile a ‘‘split-mouth’’ design. One side of each mouth
Carolina Araya, Departament of Restorative Dentistry, was randomly treated with 37.5% HP, and the
University of Chile Dental School, Santiago, Chile Pablo other side was bleached with 6% HP. Each
Angel, Departament of Restorative Dentistry, University of group received 3 to 12 minutes of treatment
Chile Dental School, Santiago, Chile
with the respective gel applications. Two ses-
*Eduardo Fernandez, Department of Restorative Dentistry, sions of bleaching were carried out each week.
University of Chile and Instituto de Ciencias Biomédicas,
Universidad Autónoma de Chile, Santiago, Chile
A spectrophotometer was used to measure the
total variation of color (DE), and a subjective
*Corresponding author: 11 de Septiembre 1881 of 2108,
Santiago 7500505, Chile; e-mail: edofdez@yahoo.com
evaluation was made with Vita Classical scale
(DSGU) between the baseline (session 1) and
DOI: 10.2341/17-229-C
different measurement times. We compared DE
 Operative Dentistry

and DSGU for both agents using the Mann- year.6,8 However, the gel was catalyzed by light-
Whitney test (a=0.05). emitting-diode or laser light. There are no reports on
Results: In both groups, there was variation low concentrations of HP gels without light assis-
among the initial color and the color in the tance that demonstrate the effectiveness of tooth
different measurement times. In the month bleaching.
after the treatment was completed, DE was 9.06 There has been a large increase in the demand for
in the 37.5% HP group and 5.69 in the 6% HP improving cosmetic appearance, especially dental
group. The difference between the two groups appearance. New reports link personality factors
was statistically significant starting in the with choosing tooth whitening.11,12 Thus, it is
second session (p=0.000). important to assess the possible changes in esthetic
Conclusion: There was a significant difference self-perception and the psychosocial impact among
between the effectiveness of the bleaching gel patients undergoing clinical tooth whitening using
concentrations of 37.5% and 6% HP according validated instruments. The effects of whitening can
to spectrophotometer measurements and sub- last for one year or more.13 Thus, it seems relevant to
jective evaluations. There was also a positive consider whether possible psychosocial changes
effect on psychosocial impact and esthetic self- occur beyond the first few weeks after bleaching.
perception among patients. Patients who undergo extracoronal tooth whitening
experience a positive impact on psychosocial quality
INTRODUCTION of life and self-perception.6
Therefore, the present study investigated whether
Hydrogen peroxide (HP) is commonly used to treat
it is possible to achieve equally satisfactory results
the discoloration of teeth. It is a powerful oxidizer
between 37.5% HP gel and 6% HP gel in a split-
that separates the molecules of chromophores that
mouth model. We also assessed the psychosocial
remain on the teeth. The molecules become smaller
impact and self-perception of esthetics generated by
molecules that reflect less light, which creates a
extracoronaral tooth whitening. The first null hy-
whitening effect.1 Evidence suggests that tooth
pothesis was that there would be no difference in the
whitening is safe and minimally invasive. However,
effectiveness of the whitening gels at one month
some researchers believe that whitening could
follow-up. The second null hypothesis was that the
potentially lead to structural changes in the teeth
whitening would not affect the quality of life of
tissues.2
patients.
The effects caused by whitening are controversial,
especially for gels with high concentrations.3 The METHODS AND MATERIALS
effects and the diffusion of HP on hard tooth tissues
Study Design
depend on the concentration and contact time.4 This
has led some manufacturers to produce gels with This study was a double-blind, randomized, prospec-
lower concentrations of HP. The European Union tive clinical trial. The study was conducted according
banned the use of whitening agents at concentra- to the recommendations of CONSORT (Consolidated
tions above 6%.5 Despite this, patients continue to Standards of Reporting Trials),14 as shown in Figure
demand these treatments. Therefore, it is necessary 1, as well as the principles of the Helsinki Conven-
to investigate bleaching agents to confirm their tion.15 The study was approved by the ethics local
efficacy and safety under the new requirements. committee (approval number 15/001), and the trial
was registered (NCT03217994).
Efforts are currently focused on achieving effec-
tiveness with low concentrations of peroxide while
minimizing the contact time between the tooth and Sample Description
bleaching gel to reduce the adverse effects.6-8 This Sample Selection—A total of 35 patients were
could be performed using low concentrations of selected from the clinic of the Faculty of Dentistry at
dental whitening agents. However, it must be the University of Chile. The patients had been
confirmed that the effectiveness does not differ seeking whitening treatment and volunteered to
significantly from that of the high concentrations participate in the study. The selected patients had to
that are usually used.9,10 A recent study followed a meet all the inclusion criteria and signed informed
cohort of patients treated with a low concentration consent forms adopted by the Ethics Committee of
HP gel. The study showed acceptable results and a Faculty of Dentistry. The inclusion criteria were as
low rebound of color at nine months and at one follows:
Bersezio & Others: Bleaching with 37.5% and 6% hydrogen peroxide

Patients who experienced any pathologies that

prevented them from entering the study (such as
caries, periodontal disease, or dental sensitivity)
were directed for treatment to the dental clinic of
the Faculty of Dentistry of the University of Chile.
Sample Size—The sample size (n) was determined
based on similar studies.6 A minimum n of 25
patients per group was determined. A significance
level of 5% was considered at (1-"b) 0.84 with a
dropout rate of 5%, resulting in 35 patients.
Study Location—Treatments were carried out at
the clinic of the Faculty of Dentistry of the
University of Chile. During this period, volunteers
were supervised by the researchers.

Procedure
Determination of Study Group—The study was
carried out with a ‘‘split-mouth’’ design. Bleaching
agents (HP) were randomly (pararell groups) calcu-
lated and assigned (SPSS 21, IBM, New York, NY,
USA) to each hemiarch. The two operators were
Figure 1. Flow diagram of the clinical trial. unaware of the product being used. To achieve this,
auto-mix syringes from a Polaoffice þ whitening kit
were used (SDI Limited, Bayswater, Australia). The
- Age over 18 years (both sexes) syringes contained HP in the form of a thixotropic
- Six present maxillary anterior teeth gel at a concentration determined by the manufac-
- No caries turer and marked properly. Each gel syringe was
- No restorations (in the maxillary anterior teeth) relabeled with a key number depending on the
concentration of the agent, which was determined
- No previous whitening treatments
by an operator who was unaware of the procedures.
- Tooth color value of A3 or darker (Vita Classical
scale, Vita Zahnfabrik, Bad Säckingen, Germany), All color measurements were performed on the
which was determined with a spectrophotometer maxillary central incisors by different operators
(Vita Easy Shade Compact, Vita Zahnfabrik, Bad from those mentioned. In one group, the hemiarch
Säckingen, Germany) on the middle third of the (canine, lateral, and central incisors) was bleached
vestibular surface of the maxillary central incisors with 37.5% HP (Polaoffice þ 37.5% SDI Limited). In
the other group, the hemiarch was bleached using
Patients were excluded based on the following 6% HP (Polaoffice þ 6% SDI Limited).
criteria:
Preliminary Phase—The procedures to be per-
formed were verbally explained, and then each
- Pregnant or nursing mothers volunteer read and signed an informed consent form.
- In pharmacologic treatment In each case, a heavy silicone matrix (Speedex Putty,
- Bruxism and patients who reported prior tooth Coltene Whaledent, Altstätten, Switzerland) was
sensitivity prepared for both maxillary central incisors. These
- Previous tooth whitening (either at home or matrices were perforated at the height of the union of
professionally) the cervical third and the middle third of the
- Visible dental cracks, developmental defects, or vestibular tooth face to standardize the color mea-
teeth stained by tetracycline or fluorosis in the surements with the spectrophotometer (Easyshade
maxillary anterior teeth compact, Vita Zahnfabrik, Bad Säckingen, Germany).
- Treatment with fixed appliances Another reason was to create a perfect fit with the
- Periodontal disease or cancer nozzle of the spectrophotometer to help control the
- Presence of noncarious cervical lesions or endodon- passage of light to the measurement site. The color of
tics in the maxillary anterior teeth each maxillary central incisor was measured using
 Operative Dentistry

the spectrophotometer, which was previously cali- (B1) to darkest (C4) according to the color. Although
brated according to the manufacturer’s instructions. the Vita Classical scale is not linear in the truest
Bleaching Protocol—Two whitening sessions were sense, we treated the changes as continuous with a
carried out with intervals of one week. At the linear ranking as in previous clinical trials of dental
beginning of each session, dental prophylaxis was bleaching.17 Two calibrated evaluators with a j
done with a brush at low speed. Stone pumice and value of 0.85 recorded the shades of both central
water were used on the maxillary anterior to remove incisors at baseline, at each session, one week after
the surface layer from the enamel so that it would treatment, and one month after. The perceptibility
not alter the effectiveness of the gels. We used a threshold considered was 2.7 DE units.18 The color
plastic lip separator and a light-cured blue resin was registered over the middle third of the labial
gingival barrier (Gingival Barrier, SDI Limited) to surface as established by the American Dental
protect the soft tissue. We homogeneously applied Association (ADA) guidelines.19 The color difference
the different gels on the vestibular surfaces of each was calculated as the number of shade guide units
hemiarch. One hemiarch was treated with 37.5% that the tooth changed toward the lighter end of the
HP, and the other was treated with 6% HP shade guide (DSGU). At the one-month control, the
(Polaoffice þ, SDI Limited). evaluation was done after dental prophylaxis and
after waiting 15 minutes for rehydration of the teeth
The protocol included two sessions of treatment before color assessment.
with three applications of 12 minutes of whitening
Tooth Sensitivity Evaluation—The tooth sensitiv-
gel each session (72 minutes of total contact). The
ity (TS) after whitening was assessed by the
gels were in full contact with the tooth surface and
variables of occurrence and intensity. These data
then were removed between each application with
were obtained using a self-completed form as well as
cotton rolls, which were moistened with water and
clinical evaluations during the sessions and imme-
dried carefully. At the end of the third application,
diately after by a visual analogue scale (VAS). For
we removed the gels, washed off all the excess with
the VAS, we instructed the participants to place a
copious water, and removed the gingival barrier.
line perpendicular to a 100-mm-long line, with a zero
After Bleaching—All patients were instructed to at one end indicating ‘‘no TS’’ and the other end
avoid consuming foods with a high content of indicating ‘‘unbearable TS.’’
pigments, such as coffee, tea, wine, and beets during
the study period. Quality of Life
Controls—At the end of the first session, we Before tooth whitening, as well as one week and one
measured the tooth color with the calibrated spec- month after, all patients answered two question-
trophotometer (Vita Easy Shade Compact), which naires: (1) the Psychosocial Impact of Dental Aes-
has high reliability.16 One week later, the same thetics Questionnaire (PIDAQ) and (2) the Oral
protocol was repeated. The time to control sessions Health Impact Profile for dental esthetics (OHIP-
(one week and one month post whitening) was 14). The questionnaires were answered under su-
considered. pervision of an examiner, who could answer the
Tabulation of Data—Data obtained in each period patients’ questions.
were tabulated according to the three axes of the PIDAQ20 is used for psychometric assessment of
CIELAB (CIEL*a*b* 1976 color space) system (L*, the impact of psychosocial aspects of dental esthet-
a*, and b*). We also calculated DE using the ics. It consists of 23 items rated on a five-point Likert
Pythagorean Theorem as follows: scale (0 for total disagreement and 4 for full
h i1=2 agreement). The items are divided into four sub-
DE ¼ ðDLÞ2 þ ðDaÞ2 þ ðDbÞ2 scales consisting of six questions on positive dental
self-confidence, eight questions on three negative
dimensions of psychological impact, three questions
The variation of each parameter at different times concerning esthetics, and eight questions on social
was always calculated in relation to the initial values impact. The total score is between 0 and 72 points. In
(the color measurement prior to the first session of addition, an analysis was done according to the
whitening). subscales. A greater dental self-confidence subscale
Subjective Evaluation—For the subjective evalua- score indicated greater self-confidence. However,
tion, we used the Vita Classical shade guide (Vita high scores on the subscales of psychological and
Classic, Vita Zahnfabrik), which ranges from lightest social impact indicated adverse effects of esthetics.
Bersezio & Others: Bleaching with 37.5% and 6% hydrogen peroxide

Table 1: Baseline participant characteristics

RESULTS

Baseline Features Groups (Hydrogren Description of the Sample

Peroxide Percentage) This study evaluated 110 patients who voluntarily
37.5% 6% came to the local Faculty of Dentistry clinic. Using a
Age (y; mean 6 SD) 27.36 6 9.28 ‘‘split-mouth’’ design, each group (37.5% and 6% HP)
Minimum age (y) 20 comprised n=35 patients (selected according to the
Maximum age (y) 53 inclusion criteria). However, two patients left the
Male (%) 51.5 study due to noncompliance with the appointments,
L* (mean 6 SD) (p.0.05) 85.85 6 3.12 85.43 6 3.21* so only 33 patients were considered in the analysis
a* (mean 6 SD) 0.22 6 1.23 0.33 6 1.50* (Figure 1). The average age of the sample was 24
b* (mean 6 SD) 28.06 63.39 28.64 6 3.88* years old, with a range of 20 to 47 years. Their
Baseline Vita Classical SGU 9 (9:12) 9 (9:12) baseline features are presented in Table 1.
median (min:max)
Abbreviation: SD, standard deviation. Effectiveness of Whitening
* p.0.05 between groups.
Objective Evaluation—Both groups achieved effec-
tiveness (DE . 5) with differences of more than 3 DE
OHIP-1421 is an instrument for evaluating esthet-
units at one month after bleaching (p,0.001; Table
ic self-perception. The questions are also answered
2).
on a five-point Likert scale indicating ‘‘very often’’
(4); ‘‘quite often’’ (3); ‘‘occasionally’’ (2); ‘‘almost Subjective Assessment—Both groups had a whit-
never’’ (1); and ‘‘never or unknown’’ (0). A greater ening effectiveness of more than 5 SGU units at one
score indicated a worse patient self-perception of the month after whitening, but there was a statistically
cosmetic dentistry. To calculate the OHIP-14 score significant difference between groups (p,0.05; Table
for each patient, the scores of the 14 questions were 3).
added to generate overall scores ranging between 0 Sensitivity—Only four patients noticed sensitivity,
and 56 points. and the mean sensitivities after the first session
according to VAS were 0.48 6 1.20 in the 37.5%
Statistical Analysis group and 0.41 6 1.31 in the 6% group. However,
differences between groups were not statistically
The Shapiro-Wilk test was used to determine the
significant (p=0.531). The mean sensitivity after the
normality of the dataset. The data distribution was
second session was 0.41 6 1.20 in the 37.5% group
not normal, so the Mann-Whitney test was used to
and 0.35 6 1.37 in the 6% group, but again the
compare the efficacy and sensitivity results in both
differences were not statistically significant
groups. The Wilcoxon test was used to compare the (p=0.450).
variations between different measurement times.
The statistical tests were performed using the
Quality of Life
software SPSS 21.0 (IBM, New York, NY, USA).
Descriptive statistics of the scores on the scales of Psychosocial Impact (PIDAQ)—At one week and
the PIDAQ and OHIP-14 esthetic surveys were one month, there were statistically significant
determined, and the results were compared for differences from the baseline values of PIDAQ,
different evaluation time points using the Wilcoxon which indicate a positive impact on the factors
test. Besides the selected demographic variables (Table 4).
such as age and sex, the data were coded and treated Esthetic Self-Perception (OHIP)—All factors ex-
anonymously. cept functional limitation had significantly lower

Table 2: Comparison of DE values at different times.

Assessment Points Color Change by DE
37.5% Hydrogen Peroxide 6% Hydrogen Peroxide Mann-Whitney Test
Baseline vs one week during bleaching 3.79 6 4.43 3.53 6 3.04 0.493
Baseline vs two weeks during bleaching 6.95 6 3.33 4.37 6 2.34 0.001
Baseline vs one week after bleaching 8.94 6 3.07 6.34 6 3.82 0.001
Baseline vs one month after bleaching 9.06 6 2.96 5.69 6 3.06 0.000
 Operative Dentistry

Table 3: Comparison of DSGU values at different times

Assessment Points Color Change by DE
37.5% Hydrogen Peroxide 6% Hydrogen Peroxide Mann-Whitney Test
Baseline vs one-week bleaching 3.90 6 1.90 3.52 6 1.90 0.345
Baseline vs before two-week bleaching 4.77 6 2.10 4.29 6 2.10 0.325
Baseline vs two-week bleaching 6.68 6 1.60 6.26 6 1.60 0.196
Baseline vs one week after bleaching 6.68 6 1.60 6.10 6 1.7 0.106
Baseline vs one month after bleaching 6.71 6 1.80 5.87 6 1.8 0.019

values compared with the baseline. At one month, all From the measurements at the start of the second
factors measured had a statistically significant session, we began to see a separation between the
difference compared with the baseline. In the overall values of each group, with a difference of more than
score, the difference was also significant at one week two units in DE that increased over time (Table 2).
and one month (Table 5). Despite the differences between the final values,
only one patient noticed a difference between both
DISCUSSION hemiarches (was retreated). Prior to bleaching, we
told the patients that we would work to match the
This study compared the effectiveness of tooth
colors of the different hemiarches if they were
whitening with gels containing 6% and 37.5% HP
unhappy with the esthetic results. This probably
without light treatment. Tooth color was measured
occurred because the difference between the colors of
up to the one month after whitening using a both groups was not significant enough due to the
spectrophotometer and a subjective assessment. thresholds of each person.
Based on the results, we rejected the null hypothesis
that bleaching with 6% HP was as effective as that Related to the objective effectiveness, dental in-
with 37.5% HP. office whitening systems can be categorized into
groups of high or low concentration of HP (.35% or
Prior to the intervention, the spectrophotometer ,20%, respectively). Highly concentrated groups
measurements showed that there was no significant traditionally show a high effectiveness, with more
difference between the initial parameters of the two than eight units of DE in color change, in treatments
groups (Table 1) on any of the three axes of the color of around 100 minutes of segmented contact in
system. This is an advantage of the split-mouth different sessions using different protocols.24,25 In
design, because there is greater variability between contrast, low concentrated agents traditionally have
the characteristics of each hemiarch in the same been less effective, with DE of around five
patient.7,22,23 Bleaching was considered effective in units.10,26,27 In our study we obtained color changes
both groups because they presented a DE of at least
five units during the control month (G [6%]: DE =
Table 5: Effect of bleaching in the esthetic self-perception
5.69). In the 37.5% group, the highest value of DE evaluated with the OHIP questionnaire
occurred in the monthly control (DE = 9.06).
Dimension Time Points
Baseline 1 Week 1 Month
Table 4: PIDAQ results at different time points After After
Bleaching Bleaching
Dimension Time Points
Functional limitation 3 (0:7) 3 (0:6) 2 (0:6)a
Baseline 1 Week 1 Month a
After After Physical pain 3 (0:7) 2 (0:4) 2 (0:6)a
a
Bleaching Bleaching Psychological discomfort 4 (0:7) 3 (0:6) 3 (0:5)a
a a a
Dental self-confidence 18 (10:63) 23 (15:68) 23 (16:30) Physical disability 1 (0:6) 1 (0:4) 0.5 (0:2)a
a a a
Social impact 17 (9:34) 16 (8:34) 13 (8:29) Psychological disability 1 (0:5) 0.5 (0:3) 0 (0:3)a
Psychological impact 19 (8:28) 15 (6:26)a 13 (6:23)ab Social disability 0 (0:4) 0 (0:3)a 0 (0:2)a
a a a
Esthetic concern 7 (3:15) 6 (3:10) 5 (3:10) Handicap 0 (0:4) 0 (0:3) 0 (0:3)a
ab a
Sum 60(44:86) 59 (38:92) 55 (36:75) Sum 14 (6:33) 11 (3:21) 10 (0:19)ab
a a
Statistically significant difference (Wilcoxon test, p,0.05) versus baseline. Statistically significant difference (Wilcoxon test, p,0.05) versus baseline.
b b
Statistically significant difference (Wilcoxon test, p,0.05) versus 1 week Statistically significant difference (Wilcoxon test, p,0.05) versus 1 week
after bleaching. after bleaching.
Bersezio & Others: Bleaching with 37.5% and 6% hydrogen peroxide

around six units of DE with a low concentrated gel. The intensity and occurrence of sensitivity were
However, this effectiveness is similar to low concen- low, which could be related to the use of both gels
tration gels assisted by a LED/laser light. The gel with a more neutral pH. This coincides with the
used in this study comes with the alkaline compo- results of a recent clinical trial that used the same
nents separated in two compartments that are self- gel with a concentration of 37.5%.24 That study
mixed at the time of application, reducing the reported lower sensitivity than when using gels with
possibility of inactivation of the HP, perhaps repre- a more acidic pH. Interestingly, there was no
senting an advantage in the effectiveness of the difference between the reported sensitivity between
product compared with other forms of presenta- the two gels of different concentrations, which could
tion.24 be due to the strict selection of patients without
Regarding the variations in DE, the results of this previous history of sensitivity.
study are in accordance with a previous study by In general, traditional highly concentrated HP
Martin and others,22 who also compared the effec- gels generate higher values of sensitivity in intensity
tiveness of 6% with 37.5% hydrogen peroxide. and duration.25 The literature reports prevalence of
However, they modified both agents with nitrogen patients with sensitivity induced by dental whiten-
titanium dioxide and activation by LED light. ing between 45% and 90% with moderate intensity
However, Martin and others obtained one difference and in some cases high.30 However, the new lower
in that the values of DE were lower in both groups in concentrations of HP (15% or 6%) definitely report
the monthly control (2.41 units). Their 37.5% group very low sensitivity both in prevalence and intensi-
obtained lower values than our 37.5% group, and ty.7,9,10 Clearly the most common adverse effect of
their 6% group obtained better performance than our tooth whitening is being controlled by the emergence
6% group. of new whitening gel technologies.
In addition, although there was a statistically The second hypothesis was rejected because we
significant difference between the two groups ac- noticed a positive effect on the psychosocial impact
cording to the objective spectrophotometer measure- and on the esthetic self-perception of the patients.
ments, the difference in DE was less than four units The study results showed that there were significant
and did not show a significant difference from changes in the values of the PIDAQ and OHIP-14
subjective assessments using color tablets. Further- questionnaires after comparing the scores prior to
more, no patient was unhappy with the results based clinical whitening with those obtained after the
on the subjective assessments. Notably, in this procedure. This difference in values showed that
clinical study, the 6% gel did not require light there was a change in patients’ psychosocial aspects.
assistance as in the trial published by Martin and Thus, by improving the dental esthetics through
others.22 This reduces the cost of the treatment and whitening, there was a positive change in the
is advantageous for the clinician. psychosocial impact and self-perception of these
In vitro studies have looked at reducing the patients. There were no significant differences
concentration of the bleaching agent. There is a between the post-treatment measurements. There-
significant decrease in the penetration of HP and its fore, it can be concluded that tooth whitening is a
byproducts through the mineralized tissues of the modifier of psychosocial aspects and the self-percep-
tooth to reach the pulp.29 Consequently, the effects tion of esthetic dental factors. Once the procedure
on the pulp tissue can be reduced, and tooth was over, there were no other esthetic changes.
sensitivity can be avoided. This is why efforts have Dental self-reliance measures the influence of
focused on demonstrating the effectiveness of new esthetic dentistry on the self-image of an individual.
bleaching protocols and agents with lower concen- The appearance of the mouth and smile play
trations.10 Surely, future recommendations will important roles in the assessment of facial attrac-
involve the use of low concentrations for tooth tiveness, which undoubtedly contributes to improv-
whitening. ing self-esteem.31 The results of this study suggest
One of the strengths of this research in compar- that extracoronal tooth whitening produces an
ison with previous studies is the split-mouth design, increase in dental self-confidence, which remains
which reduces the variability between the groups over time. This finding shows that this factor is
studied by using every patient as their own control.23 associated with more favorable attitudes toward oral
However, there was no previous certainty that the health and a higher degree of satisfaction with
results of both products would be similar. respect to better self-image.32
 Operative Dentistry

The measurement of social impact is aimed at others, and they could result in dysphoric states.35
assessing potential problems that an individual may This study showed that there is an increase in
face in social situations due to a subjectively psychological well-being after tooth whitening,
unfavorable dental appearance. The third dimension which remained steady over time. Whitening im-
of psychological impact evaluates an individual’s proves a patient’s own self-satisfaction, and they feel
feelings of inferiority or unhappiness in comparison better and safer when they have teeth with a color
to others. The fourth dimension concerns esthetics that pleases them. The PIDAQ and OHIP-14 tools
and includes data related to the concern or disap- demonstrated that there are positive changes in both
proval that an individual’s dental appearance gen- the psychosocial well-being of patients and the self-
erates when they look at the mirror, photographs, or perception of cosmetic dentistry at the end of the
videos.20 In terms of these three negative dimensions whitening period. These changes also remained at
(social impact, psychological impact, and esthetic one and three months after treatment, which
concerns), the results obtained show a decrease in corroborates the hypothesis that the psychosocial
scores when comparing data from the beginning of impact and esthetic self-perceptions are positively
the treatment versus the assessments at one week changed by extracoronal tooth whitening.
and one month after whitening. Therefore, extrac-
oronal tooth whitening generates an immediate and It would be useful in future research to include
short-term positive psychosocial impact. comparative studies contrasting color changes after
extracoronal tooth whitening (either through spec-
In the total scores obtained from the OHIP-14 trophotometer or shadeguides) versus the changes in
questionnaire, there was a statistically significant psychosocial aspects of cosmetic dentistry patients in
decrease compared with the evaluation prior to the medium and long term. It would also be desirable
whitening. This indicates that extracoronal whiten- to compare the psychosocial changes of patients in
ing produces a substantial improvement in the self- relation to the different techniques of extracoronal
perception of cosmetic dentistry in patients and a
bleaching (in-office vs at home) and with different
noticeable decrease in the dimensions of physical,
concentrations. The esthetic self-perception and
psychological, and social disabilities, as well as
psychosocial impact could also be compared among
physical pain and handicaps. These values decreased
patients undergoing tooth whitening vs untreated
significantly with the treatment and show important
patients. This would shed more light on whether the
implications in biopsychosocial health approaches,
positive changes are due to bleaching and not other
because the disadvantages experienced due to
factors. Finally, future studies could use other
cosmetic dental problems may profoundly affect a
questionnaires to measure whether there are im-
person’s self-esteem, interactions, adaptations to
provements in the quality of life of a patient after
their environment, personal relationships, job op-
undergoing tooth whitening. Although this study
portunities, and fundamental aspects that affect
quality of life.32,33 shows significant differences in quality of life
measurements, it is recommended to carry out
Regarding the dimension of functional limitation, studies with controls of parallel groups of patients
the analyses showed a positive effect at just one that are not subjected to tooth whitening to test the
month after treatment. No changes occurred after controlled effect on the quality of life.
one week. This finding demonstrates that the effect
is not immediate, and the patient requires interac- CONCLUSIONS
tion with their environment and a chance to build
interpersonal relationships to accomodate this pos- Whitening with both 37.5% HP and 6% HP is
itive change.34 This positive effect was maintained effective according to measurements with a spectro-
for at least three months. The dimension that had photometer. There was a statistically significant
the greatest improvement was psychological discom- difference between the effectiveness of bleaching
fort. The improvement was observed at one week between concentrations starting from the second
after completing treatment and remained constant session of treatment.
during all subsequent evaluations. These improve- There is a positive psychosocial impact in patients
ments are consistent with the results obtained in a undergoing extracoronal tooth whitening when
study from 2015, in which there were also improve- comparing the baseline measurements with those
ments in the different dimensions of OHIP-14.22 taken one week and one month after treatment.
Comparison processes play an important role in There is an increase of self-confidence and psycho-
psychosocial well-being and feelings of inferiority to logical well-being compared with the start of the
Bersezio & Others: Bleaching with 37.5% and 6% hydrogen peroxide

whitening with the measurements at one week and year follow-up Journal of Esthetic and Restorative
one month after treatment. Dentistry 29(5) 339-345.
9. Bortolatto JF, Trevisan TC, Bernardi PS, Fernandez E,
Dovigo LN, Loguercio AD, Batista de Oliveira Junior O, &
Acknowledgments
Pretel H (2016) A novel approach for in-office tooth
The author dedicates this article to his two children, Elisa and bleaching with 6 % HO/TiO_N and LED/laser system-a
Eduardo due to their enormous inspiration. Class of Dentistry controlled, triple-blinded, randomized clinical trial Lasers
1994 - Universidad de Chile. Fondecyt 1170575 in Medical Science 31(3) 437-444.
10. Bortolatto JF, Pretel H, Floros MC, Luizzi AC, Dantas
Regulatory Statement AA, Fernandez E, Moncada G, & de Oliveira OB, Jr.
This study was conducted in accordance with all the (2014) Low concentration H2O2/TiO_N in office bleach-
provisions of the approval of the Local Ethics Committee ing: a randomized clinical trial Journal of Dental
guidelines and policies of the Comité de Etica Fouch. The Research 93(Supplement 7) 66s-71s.
approval code for this study is 15/001.
11. Herrera A, Martin J, Perez F, Bonafe E, Reis A, Dourado
AL, & Fernandez E (2016) Is personality relevant in the
Conflict of Interest choice of bleaching? Clinical Oral Investigations 20(8)
The authors of this manuscript certify that they have no 2105-2111.
proprietary, financial, or other personal interest of any nature
or kind in any product, service, and/or company that is 12. Martin J, Rivas V, Vildosola P, Moncada L, Oliveira
presented in this article. Junior OB, Saad JR, Fernandez E, & Moncada G (2016)
Personality style in patients looking for tooth bleaching
(Accepted 4 February 2018) and its correlation with treatment satisfaction Brazilian
Dental Journal 27(1) 60-65.
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