Received: 14 November 2019 Revised: 5 June 2020 Accepted: 10 June 2020

DOI: 10.1111/jerd.12617

RESEARCH ARTICLE

Over-the-counter bleaching agents can help with tooth

whitening maintenance

Olívia Santana Jorge Undergraduate Student |

Carolina Noronha Ferraz de Arruda DDS, MSc, PhD |
Rafaella Tonani Torrieri BAcc, MSc | Rocio Geng Vivanco DDS, MSc Student |
Fernanda de Carvalho Panzeri Pires-de-Souza DDS, MSc, PhD

Department of Dental Materials and

Prosthodontics, Ribeir~ao Preto School of Abstract
Dentistry, University of S~ao Paulo, Ribeir~ao Objective: This study evaluated the influence of over-the-counter agents on the
Preto, S~ao Paulo, Brazil
maintenance of color and microhardness of the enamel after home bleaching
Correspondence protocol.
Fernanda de Carvalho Panzeri Pires-de-Souza,
Department of Dental Materials and Materials and methods: Specimens of bovine teeth (6 × 6 × 2 mm) were prepared,
Prosthodontics, Ribeir~ao Preto School of and color (Easyshade, VITA) and microhardness (HMV-2, Shimadzu) readings were
Dentistry, University of S~ao Paulo (FORP-
USP), Av. Do Café, s/n
, Bairro Monte Alegre, performed. All the specimens were bleached using 22% carbamide peroxide (22%CP),
CEP 14040-904 Ribeir~ao Preto – S~ ao Paulo. except for the control group, and then separated into seven groups (n = 10) according
Brazil.
Email: ferpanzeri@usp.br to the interaction of toothpaste (whitening, conventional, and whitening with perox-
ide) and mouth rinse (whitening and conventional). The study simulated 1 year of
Funding information
Sao Paulo Research Foundation (FAPESP), toothbrushing (Pepsodent, MAVTEC) and mouth rinse by immersion. After that, final
Brazil, Grant/Award Number: 2017/09295-4 color and microhardness measurements were performed. Data were analyzed by
one-way ANOVA, Tukey's test (P < .05).
Results: The group submitted to 22%CP + whitening toothpaste + whitening mouth
rinse showed higher color maintenance (P < .05) than the control group. The percep-
tion of whitening of teeth (ΔWID) was higher than the color change (ΔE00). There
was a decrease in microhardness after treatment with 22%CP + conventional
toothpaste + whitening mouth rinse.
Conclusions: Over-the-counter products can help with the maintenance of tooth
whitening after bleaching with carbamide peroxide; however, special attention
should be given since the association of products can also reduce the microhardness
of the dental enamel.
Clinical significance: The association between whitening toothpastes and mouth
rinses might be beneficial for maintaining color during 1 year after bleaching
treatment.

KEYWORDS

bleaching agents, color, hardness, tooth bleaching

J Esthet Restor Dent. 2020;1–7. wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals LLC. 1

2 SANTANA JORGE ET AL.

1 | I N T RO DU CT I O N Color (Easyshade, VITA; Bad Säckingen, Germany) and micro-

hardness (HMV-2, Shimadzu, Tokyo, Japan) were then analyzed. For
Esthetic appearance has become increasingly important nowadays, color analysis, the standard observation followed the CIEDE 2000 sys-
and can affect psychological, social, and interpersonal relationships. tem, defined by the formula: ΔE00 = (ΔL/KL  SL) + (ΔC/
The color of teeth is one of the most determinant factors for patients' KC  SC)2 + (ΔH/KH  SH)2 + RT  (ΔC/KC  SC)X(ΔH/KH  SH)0.5, where
satisfaction and self-esteem.1 Due to being a conservative approach, ΔL0 , ΔC0 , and ΔH0 are the differences in lightness, chroma, and hue
tooth whitening has become the most popular esthetic treatment in between two specimens and RT (rotation function) is a function that
dentistry.2 In this procedure, gels with hydrogen or carbamide perox- accounts for the interaction between chroma and hue differences in
ide are employed and their application techniques vary according to the blue region.
the concentration of the activating agent, which bleach teeth through SL, SC, and SH are the weighting functions for the lightness,
3
oxidation-reduction reactions of free radicals. chroma, and hue components, respectively. KL, KC, and KH are the
Currently, the technique of home bleaching with individual trays parametric factors according to different viewing parameters that
is being increasingly used.4 In addition, the high level of demand for were set to 1.
this type of treatment has resulted in the growth of a market for Color measurements were made against a white background
bleaching products, including bleaching toothpastes and mouth- (White Standard Sphere for 45
, 0
Reflectance and Color Gardner
washes that can be easily found in supermarkets and drugstores, Laboratory, Germany) and in a standardized lightbox (Gester Interna-
referred in the literature as “over-the-counter” (OTC) products,5 tional; Fujian Province, China) with a neutral-gray (Munsell N-7) back-
which do not need a dentist's prescription for use. ground and under primary standard illuminant D65, which simulates
OTC products have different whitening mechanisms. For mouth the light spectrum of the day.
rinses and strips, the mechanism is based on the presence of hydrogen After activation, 19 optical fibers of spectrophotometer were lit
peroxide; while toothpastes focus on surface abrasion, removing sur- and emitted a beam of light at 45
on the surface of the material. The
face stains.6 The incorporation of chemical agents, such as hydrogen light is reflected at 0
and recorded as the coordinates L*, a*, and b*
peroxide in low concentrations, increase bleaching power by reacting specimens' values. Three color measurements were made for each
with chromogenic molecules, and dissolving tooth enamel/dentin specimen, which were considered initial coordinate values. Further-
stains, producing significant color change.7 more, the CIELAB-based whiteness index (WID) was calculated by the
Literature shows that OTC agents, as toothpaste8,9 and mouth formula: WID = 0.511 L* − 2.324a* − 1.100b* to correlate the visual
10
rinse, are not as effective, by themselves, as the home bleaching gel. perception of whitening, avoiding the subjective visual factor in dental
However, due to their effectiveness in removing stains,6 they might color measurement.14 Positive values of WID indicate higher white-
be helpful in the color maintenance after whitening procedures, ness values, and low (or negative) values, indicate lower values of
supervised by the dentist. In addition, it is important to evaluate not whiteness.14
only the influence of these products on color maintenance after Knoop microhardness (HMV-2; Shimadzu, Tokyo, Japan) were
bleaching, but also their effect on tooth properties, especially the measured with a vertical static load of 25 g for 5 seconds at ×40 mag-
hardness,11 predictor of the loss of mineral content of enamel,12 and nification. Data were calculated by using the formula: KHN = 1, 451
d2
F
,
resistance to fracture.13 where KHN is Knoop Hardness number; F is 25 g, and d is the length
The aim of this study was to evaluate the maintenance of color of largest diagonal indentation. Specimens were measured in three
and microhardness of the dental enamel after home bleaching proce- segments: in the center and two marks at a distance of 1 mm to the
dure and 1 year after using the OTC products. The null hypothesis left and to the right, respectively. The means of these three measures
was that the association of OTC products would produce no differ- were considered as the initial microhardness values. The change in
ence in the color and microhardness after home bleaching procedure, microhardness (before and after each treatment) was calculated by:
irrespective of the association employed. KHN = KHNf − KHNi, where KHNf represents final microhardness
measurement and KHNi is the initial measurement.
After the initial measurements, samples were randomly assigned
2 | MATERIALS AND METHODS into seven groups (n = 10) (Table 1) according to the treatment proto-
col, considering the interaction of the bleaching products (Table 2):
The sample size was based on data obtained from a pilot study whitening 22% carbamide peroxide gel (22%CP); a toothpaste (con-
(n = 10) and determined on www.openepi.com, with a significant level ventional, whitening, and whitening with peroxide); and mouth rinse
of 5%. The statistic power of the study was 93.06%. (conventional and whitening).
Bovine teeth were cut (Isomet 100 Buehler, Illinois) in fragments The whitening treatment with 22%CP was carried out as rec-
(6 × 6 × 2 mm) that were embedded in acrylic resin, with the buccal ommended by the manufacturer, for 14 days, simulating the gel appli-
surface parallel to the horizontal plane. The enamel surface of the cation by the patient for 1 hour per day. The gel was applied placing a
specimens was gently flattened using 600, 1200, and 2000 grit SiC small drop (0.2 mL) in the center of the sample with a syringe, and
abrasive paper for 15 seconds, in order to uniform samples surface then it was better distributed and spread throughout the entire sam-
roughness. ple with an applicator to form a uniform layer.15 After 1 hour, the
SANTANA JORGE ET AL. 3

specimens were rinsed with distilled water, to completely remove the To simulate 1 year of use of mouth rinse, samples were submitted
product. Then, they were immersed in distilled water for 23 hours to 12 cycles of 1 minute of immersion. At the end of each cycle, they
until the next application. This procedure was performed for 14 days. were washed in running water, and then immersed in distilled water
The simulated toothbrushing (Pepsodent, MAVTEC; Ribeirao Preto, for 29 minutes (37
C). This procedure was repeated for 30 days, total-
SP, Brazil) was performed using a toothbrush (Tek, Johnson & John- ing 360 cycles.17
son; Sao Jose dos Campos, SP, Brazil) according to ISO/DTS 145692 After each treatment protocol, final color and microhardness
(Richmond et al, 2004) under 200 g load at 356 rpm and 3.8 cm path measurements were performed, according to the previously described
with back and forth movements. Toothpaste (5 g) was diluted in dis- methodology.
tilled water (5 mL) (1:1 ratio) and the toothbrushing machine simulated After all the quantitative data was collected, normality was veri-
1 year of brushing performed by a healthy individual fied by Shapiro-Wilk test (P < .05), and data for color alteration were
(14.600 cycles).16 Afterward, fragments were washed in running statistically analyzed by a parametric test (one-way ANOVA, Tukey's
water, dried with absorbent paper, and stored separately in plastic test, P < .05) and for the microhardness by Kruskal-Wallis, Dunn's
containers with 3 mL of distilled water for each fragment (37
C) until test, P < .05.
final color and microhardness measurements were obtained.

3 | RE SU LT S
TABLE 1 Groups distributions
The comparison of ΔE00 and ΔWID can be seen in Tables 3 and 4.
Groups Tray system Toothpaste Mouth rinse Regarding color change (ΔE00), there was difference (P < .05) between
1 Carbamide Conventional Conventional group 4 (22%CP + whitening toothpaste + whitening mouth rinse)
peroxide and group 7 (control: conventional toothpaste + conventional mouth
2 Conventional Whitening rinse). The other groups showed similar results to both groups. On the
3 Whitening Conventional other hand, there was no difference (P > .05) among the results of
4 Whitening Whitening color coordinates (Table 3).
5 Whitening + Conventional The WID analysis did not demonstrate difference (P > .05) among
peroxide the tested groups (Table 4). However, the values found in the WID
6 Whitening + Whitening analysis were higher than those found in the ΔE00, which may indicate
peroxide a greater perception of the color change.
7 No whitening Conventional Conventional Table 5 shows the microhardness (KHN) means and standard
agent
deviation (Kruskal-Wallis, Dunn's test, P < .05). Group 2 presented

TABLE 2 Material compositions

Treatment protocol Product Composition

22% carbamide peroxide Whiteness Perfect 22 (FGM; Carbamide peroxide, neutralized carbopol, potassium nitrate, sodium fluoride,
(22%CP) Joinville, Santa Catarina, Brazil) moistener (glycol), deionized water
Conventional toothpaste Sorriso Dentes Brancos (Colgate Calcium carbonate, water, glycerin, sodium lauryl sulfate, aroma, sodium
Palmolive; Sao Bernardo do monofluorophosphate (1450 ppm fluorine), cellulose gum, tetra sodium
Campo, Sao Paulo, Brazil). RDA: pyrophosphate, sodium bicarbonate, alcohol benzylic, sodium saccharin,
68 sodium hydroxide, limonene
Conventional mouth rinse Colgate Plax Classic (Colgate 0.05% sodium fluoride, cetylpyridinium chloride, water, glycerin, propylene
Palmolive) glycol, sorbitol, poloxamer 407, aroma, potassium sorbate, saccharin sodium,
citric acid, CI 16035, blue acid 3 (CI 42051)
Whitening mouth rinse Listerine Whitening (Colgate 0.05% sodium fluoride, water, glycerin, propylene glycol, sorbitol, tetra
Palmolive) potassium pyrophosphate, polysorbate 20, tetra sodium pyrophosphate,
citrate zinc, pvm/ma copolymer, aroma, benzylic alcohol, sodium fluoride
(225 ppm fluorine), saccharin sodium, blue acid 3 (CI 42051)
Whitening toothpaste Colgate Luminous White (Colgate Sodium fluoride (1450 ppm fluorine), water, sorbitol, hydrated silica, PEG-12,
Palmolive). RDA: 175 sodium lauryl sulfate, aroma, cellulose gum, potassium hydroxide, tetra
sodium pyrophosphate, phosphoric acid, cocainapropyl betaine, benzyl
alcohol, sodium saccharin, CI (77891), limonene
Whitening toothpaste with Advanced White (Arm & Hammer, 0.24% sodium fluoride, sodium bicarbonate, PEG-8, pyrophosphate tetra
peroxide Church & Dwight; St Paul, sodium, PEG/PPG copolymer 116/66, sodium carbonate peroxide, silica,
Minnesota). RDA:106 sodium saccharin, flavor, water, sodium lauryl sodium lauryl sulfate
4 SANTANA JORGE ET AL.

TABLE 3 ANOVA test for each studied variable

Sum of squares df Mean square F(DFn, DFd) P value

ΔE00 117.9 6 19.7 F(6. 63) = 2.59 .0265
ΔL 258.5 6 43.1 F(6. 63) = 1.77 .1205
Δa 11.6 6 1.93 F (6. 63) = 0.48 .8218
Δb 189.3 6 31.5 F (6. 63) = 1.29 .2771
ΔWID 829.9 6 138.3 F (6. 63) = 1.37 .2408

TABLE 4 Comparison of CIELab color coordinates and whiteness index (ΔWID) values among the groups tested

G1 G2 G3 G4 G5 G6 G7
ΔE00 9.25 (2.87) AB 9.71 (2.66) AB 8.15 (1.73) AB 10.97 (2.77) A 10.50 (2.32) AB 10.37 (3.35) AB 7.06 (3.25) B
ΔL 6.98 (4.83) 6.56 (3.32) 9.22 (7.73) 4.88 (3.31) 8.74 (5.68) 6.97 (3.98) 3.26 (4.19)
Δa −4.02 (2.07) −5.02 (2.21) −4.35 (2.18) −4.96 (2.61) −4.77 (1.68) −4.58 (0.77) −3.91 (2.04)
Δb −9.42 (3.32) −12.00 (4.91) −10.19 (5.82) −10.41 (4.72) −12.41 (5.86) −11.43 (5.14) −7.20 (4.46)
ΔWID 23.27 (7.02) 29.13 (13.87) 26.03 (11.96) 25.46 (11.96) 29.2 (9.77) 27.6 (8.42) 18.68 (8.29)

Note: Different letters in the line indicate statistically significant difference (P < .05). There were no differences between groups (P > .05) when compared
ΔL, Δa, Δb, and ΔWID.

TABLE 5 Comparison of median values (confidence interval) of microhardness (ΔKHN) among the groups

G1 G2 G3 G4 G5 G6 G7
ΔKHN 77.7 −66.0 69.3 66.5 98.3 116.9 44.2
(50.5; 233.2) (−461.3; 3.6) (11.8;184.0) (−71.5; 318.2) (−45.6; 362.1) (−93.7; 302.9) (−49.8; 125.3)
A B A A A A AB

Note: Different letters indicate statistically significant difference (P < .05).

negative values, demonstrating decrease in microhardness after treat- may influence toothpaste's RDA value, which is directly related with
ments, different from the other groups (P < .05), except group 7. All the surface roughness, wear, and consequently, in the light reflection
other sample's treatments changed the microhardness, but with no of restorative materials19; however, the toothbrush action and other
difference (P > .05) among groups. facts as saliva's ions and proteins minimize this effect.19 The tooth-
brushing simulation performed in this study may have minimized the
abrasive effect of tested toothpastes, even with different RDA
4 | DISCUSSION (Table 2), as there was no interference in Delta E between the experi-
mental groups. In addition, the whitening toothpastes also have
The aim of this study was to evaluate the use of OTC agents on the enzymes that dissolve stains caused by proteins adhered to the
maintenance of color and microhardness of the dental enamel after enamel, leading to stain removal.20
home bleaching procedure. The null hypothesis tested was that there Besides the abrasives, other toothpastes, as the one employed in
would be no difference in the maintenance, irrespective of the associ- the research (whitening toothpaste with peroxide), may contain per-
ation of products. Considering the results, it was not possible to oxides in their composition, which aims to promote a greater
accept this hypothesis because significant differences were found for bleaching effect than that produced by abrasive particles. Neverthe-
color change (ΔE00) between the group that used 22%CP + whitening less, the low concentration of the peroxide on toothpastes may not
toothpaste + mouth rinse and the control group. In addition, the promote a significantly greater effect than that already found in the
microhardness evaluation demonstrated that the association of OTC peroxide-free bleaching toothpastes. What is more, the peroxide
products with 22%CP could result in lower microhardness values, as remains in contact with the tooth only during the time of brushing; a
seen in the group that used conventional toothpaste + whitening shorter time than the period of contact of the gel, which is also used
mouth rinse after the home bleaching procedure. in higher concentration.
Whitening toothpaste can help on the maintenance of tooth color These toothpastes act on extrinsic stains and do not significantly
due to the presence of many abrasive particles in its composition,18 affect the intrinsic tooth color,7 while the bleaching treatment with
such as alumina, dicalcium phosphate dihydrate, or hydrated silica; the carbamide peroxide can produce color change resulting from its
latter found in the whitening toothpaste used in the present study. decomposition into urea and peroxide, which diffuse through the
These abrasive particles are incorporated to promote dental enamel tooth causing oxidation and the reduction of the intrinsic organic pig-
wear and whitening effect. The abrasive particles' size and structure ments in dentin, responsible for efficient tooth bleaching.21
SANTANA JORGE ET AL. 5

As regards the effectiveness of mouth rinses with bleaching As mentioned before, mouth rinses are exposed to the oral cav-
agents, studies have shown divergent results. A previous study dem- ity for a short period and must have substantivity to achieve their
onstrated similar color changes between groups submitted to best action. Nonetheless, some cationic antiseptics, such as
bleaching mouth rinses, used for 12 weeks, when compared with cetylpyridinium chloride-based (conventional mouth rinse) solutions,
home bleaching groups using 10% carbamide peroxide.18 In contrast, can be inactivated by anionic chemical compounds,26 such as sodium
other studies have reported that these mouth rinses did not show sig- lauryl sulfate and pyrophosphate, which are components found in
10,22
nificant bleaching effects, which is in agreement with the results the whitening toothpaste. In addition, pyrophosphate is an ingredi-
found in the present study. Teeth treated with a bleaching mouth ent that acts on mineral chelation and inhibition of ectopic minerali-
rinse showed no significant differences (P > .05) when compared with zation. It interacts greatly with the calcium in both solutions and on
the nonbleaching agent groups. surfaces by pairing of the ions, in which the positive charge of cal-
The bleaching mouth rinses usually contain citrate and potassium cium attracts the negative charges of oxygen in the phosphate
or sodium pyrophosphate, components that have bleaching potential anions.27
by removing surface glaze stains. Other formulations also contain Thus, it can be suggested that in group 2, the pyrophosphate
hydrogen peroxide at low concentrations, or sodium belonging to the mouth rinse may have sequestered the calcium
hexametaphosphate, an anti-tartar agent, which prevents the formation from the enamel surface that had already been previously deterio-
of stains.23 The bleaching mouth rinse used in this study contains rated due to the effect of 22%CP, therefore decreasing the
tetrapotassium pyrophosphate, tetrasodium pyrophosphate, and zinc microhardness.
citrate as bleaching/stain remover components. Nevertheless, since The other groups presented an increase in microhardness
they are in contact with the teeth for a very short period of time com- values. Bleaching products are known to be capable of causing tran-
pared with other types of products, the effectiveness and action of sient demineralization; nevertheless, some products have sodium
their components may be limited. A previous study demonstrated that fluoride or SMFP in their composition. These two types of fluoride
the period of exposure to bleaching mouth rinses was a determinant are dental enamel remineralizing substances, widely used in various
6
factor in the effects obtained. toothpaste and mouth rinses for caries prevention.28,29 The fluoride
The color alteration resulted from an increase in ΔL and a ions are able to replace the hydroxyl ions of the hydroxyapatite of
decrease in Δb and Δa indicating increase in lightning and decrease the tooth to produce fluorapatite, making it more resistant to acid
on yellow and red chroma. However, there was no difference among dissolution.30 The presence of these fluorides in the products may
the groups, considering these coordinates. Despite these results, the explain the increase in microhardness values of the samples after
perception of whitening (WID) was higher or there were no differ- the treatments.
ences when other OTC products were used. In an in vitro study, the protocols of use of the products, mode
The association of the home bleaching gel with OTC products and frequency of toothbrushing, time of use of the mouth rinses,
influenced the microhardness of the samples. Group 2 (22%CP and temperature can be well controlled. However, the oral dynamics
+ conventional toothpaste + whitening mouth rinse) presented a and the oral hygiene habits among users are very diverse. What is
wide range of value, negative, indicating a decrease in the property. more, it was not possible to analyze the action of saliva as a
Studies have shown that bleaching products can have deleterious remineralizing and buffering agent on the microhardness of dental
effects not only on enamel microhardness but also on abrasive wear enamel. Artificial saliva is known to be capable of increasing the
and surface roughness of teeth.18 The conventional toothpaste pre- color change of teeth and materials,31 the reason why the color sta-
sents sodium monofluorophosphate (SMFP) in its composition, while bility in this environment was not tested, which was a limitation of
the whitening toothpaste contains sodium fluoride. Unlike sodium the study.
fluoride, the SMFP is not an ionic fluoride salt, but rather a cova- Nonetheless, although the literature shows a reduced
lently bound compound that requires enzymatic activation by a sali- bleaching effect for OTC products, the present study showed that
vary enzyme to release fluoride. As an in vitro study, this does not the association between these whitening toothpastes and mouth
occur. On the contrary, during use, the sodium fluoride dissociates rinses might be beneficial for maintaining color during 1 year after
to provide to provide a highly reactive fluoride ion, achieving anti- bleaching treatment. Thus, further clinical studies are rec-
caries effect. ommended in order to better elucidate the effects of OTC
In group 2, the bleaching effect of carbamide peroxide was asso- products.
ciated to the bleaching mouth rinse, which has alcohol in its composi-
tion. This substance, used as a solubilizing and preservative agent,
although not promoting deleterious effects on enamel,24 may produce 5 | CONC LU SIONS
synergistic effect of the components, leading to a lower micro-
hardness. On the other hand, the presence of fluoride in the bleaching The present study demonstrated that regardless of the protocol
mouth rinse and the conventional toothpaste could provide a employed, the OTC products could maintain, for a year, the tooth
remineralizing effect. Nonetheless, higher concentration of free fluo- bleaching produced after the home bleaching procedure with carbam-
ride would be necessary.25 ide peroxide; however, special attention should be given since the
6 SANTANA JORGE ET AL.

association of conventional toothpaste with whitening mouth rinse 13. Khoroushi M, Shirban F, Kaveh S, Doustfateme S. Effect of three
can reduce the microhardness of the dental enamel. nanobiomaterials on microhardness of bleached enamel. Restor Dent
Endod. 2016;41(3):196-201. https://doi.org/10.5395/rde.2016.41.
3.196.
ACKNOWLEDGMENTS 14. Pérez MM, Ghinea R, Rivas MJ, et al. Development of a customized
The study was supported by Sao Paulo Research Foundation whiteness index for dentistry based on CIELAB color space. Dent
(FAPESP), Brazil, grant number 2017/09295-4. The authors deny any Mater. 2016;32(3):461-467. https://doi.org/10.1016/j.dental.2015.
12.008.
conflicts of interest related to this study.  Demarco FF.
15. Meireles SS, Fontes ST, Coimbra LA, Della Bona A,
Effectiveness of different carbamide peroxide concentrations used
DIS CLOSUR E STATEMENT for tooth bleaching: an in vitro study. J Appl Oral Sci. 2012;20(2):186-
The authors do not have any financial interest in the companies 191. https://doi.org/10.1590/s1678-77572012000200011.
16. Wiegand A, Kuhn M, Sener B, Roos M, Attin T. Abrasion of eroded
whose materials are included in this article.
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