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DOI 10.1007/s00784-013-1055-7
ORIGINAL ARTICLE
Received: 11 February 2013 / Accepted: 15 July 2013 / Published online: 20 August 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Objectives The aim of this clinical trial was to evaluate the
effectiveness and tooth sensitivity associated with bleaching
in patients with composite restorations in anterior teeth after
the application of a desensitizing agent.
Material and methods Bleaching was performed with 35 %
hydrogen peroxide gel in 30 patients with composite restorations in anterior teeth, divided according to the prior application of a desensitizing agent (De), or a placebo (Pl), on
maxillary superior teeth. Color was recorded at baseline,
1 week after each session and 6 months after treatment. The
experience of tooth sensitivity (TS) was recorded on an NRS
(04) during bleaching and 24 h after each session. Bleaching
effectiveness was evaluated by one-way ANOVA and Tukey's
tests (=0.05). The percentage of TS was evaluated by Fisher's exact test. For each treatment, periods were compared
using the Wilcoxon signed-rank test (=0.05), and at each
period, treatments were compared using MannWhitney U
test.
Results Both groups showed similar tooth color enhancement
and color stability after 6 months (p<0.05). No significant
difference in prevalence of sensitivity was detected between
groups (p<0.001). Higher TS intensity (median [first/third
quartiles]) was observed for Pl (1.5 [1/1.75]) compared with
De (0.5 [0/1]) during treatment (p<0.05).
Conclusions The use of a desensitizing gel (5 % potassium
nitrate, 2 % sodium fluoride) before tooth bleaching in patients
with composite restorations did not reduce the prevalence of
E. Bonaf : A. D. Loguercio : A. Reis : S. Kossatz
School of Dentistry, State University of Ponta Grossa, Ponta Grossa,
Paran, Brazil
E. Bonaf (*)
Programa de Ps-Graduao Stricto Sensu da UEPG, Departamento
de Odontologia, Campus de Uvaranas - Bloco M, Av. General Carlos
Cavalcanti 4748 - Uvaranas, 84030-900 Ponta Grossa, PR, Brazil
e-mail: elize_bonafe@msn.com
Introduction
At-home and in-office tooth bleaching treatment for tooth
discoloration are being used increasingly [1], with the inoffice option becoming more widely accepted because of the
intolerance of some patients to the use of the trays in addition
to their desire to achieve immediate results [2].
In spite of the good clinical results shown when a high
concentration (2035 %) of hydrogen peroxide (HP) is used in
more than one in-office bleaching session, clinical studies
have observed that there was high prevalence of tooth sensitivity related to this treatment modality (up to 87 %) [36].
This adverse effect is usually considered temporary and mild.
However, occasionally, it can produce considerable discomfort to the patient [7, 8].
The bleaching agent HP increases enamel permeability,
diffuses through dentin [9], and penetrates into the pulp chamber [10, 11]. The sensitivity associated with dental bleaching
may result from bleaching agents penetrating into the pulp
chamber leading to the activation of nociceptive sensors [12]
and transient inflammatory reactions [13].
In the majority of clinical studies, one of the inclusion
criteria is that patients must have sound teeth in anterior
maxilla [35, 14, 15], however, in general practice, the presence of composite restorations in anterior teeth is routinely
840
841
Randomized (n=30)
Allocation
Allocated to group De (n=15)
Received allocated intervention (n=15)
Follow up
Lost to follow-up (n=0)
Discontinued intervention (n=0)
Analyzed (n=15)
Analyzed (n=15)
842
and 4=severe) [5, 36] was used in this study. The values
were arranged into two categories: percentage of patients
that reported TS at least once during treatment (absolute
risk of TS) and overall TS intensity during and up to 24 h
after each bleaching session. The participants were also
instructed to identify the painful teeth every time they
experienced TS.
Statistical analysis The analysis followed the intention-totreat protocol and involved all participants who were randomly assigned [37]. The statistician was blinded to the study
groups.
The primary outcome, absolute risk of TS, was compared
by means of Fisher's exact test. Statistical analyses of TS
intensity, comparing the two groups in each of the assessment
points, were performed using the MannWhitney U test. As
two bleaching sessions were performed, the median score at
each assessment point was considered for statistical analysis.
Comparisons between times within each group were performed using the Wilcoxon signed-rank test. The proportion
of patients from the two groups who reported TS at least once
in the central incisors, lateral incisors, canines, and premolars
was calculated and compared by means of the chi-square test.
In this case, only restored teeth were considered.
For the subjective color evaluation, the mean and standard
deviations of shade guide units (SGU) at baseline, 1 week
after and 6 months after bleaching were compared by means
of two-way repeated measures ANOVA (groups vs. assessment time) and Tukey's test. The data from SGU and E of
the two groups were submitted to two-way repeated measures
ANOVA. A post hoc analysis (Tukey's test) was used to make
pairwise comparisons. In all statistical tests, the significance
level was set at =0.05.
Results
A total of 64 participants in an age range from 18 to 35 years
were evaluated to select 30 participants who met the inclusion
criteria. Reasons for exclusion of participants are shown in
Fig. 1. The mean age (years) of the participants in this study
was similar between the two groups (De=24.84.1 and
Pl=24.84.4). Sixty four percent of the participants were
women, 10 in the desensitizer group and 11 in the placebo
group.
The two-way ANOVA for the SGU data showed that only
the main factor assessment time was statistically significant
(ANOVA test; p<0.001). A higher degree of bleaching was
obtained after 2 weeks of treatment, and this result was stable
after 6 months for both groups (Table 1). The SGU and E
values showed a similar trend. Neither the main factors nor the
cross product interaction were statistically significant (ANOVA
test, p>0.05). This means that a degree of bleaching of
approximately four SGU was detected for both groups, and this
was stable after 6 months (Table 2).
Almost all participants in this study reported TS at least
once during treatment, and thus the absolute risk of TS was
100 % for the control group (95 % CI, 79.6100 %) and 93 %
for the experimental group (95 % CI, 70.198.8 %) for the two
groups (Fisher's exact test, p=1.0). With regard to the
intensity of TS (Table 3), participants in the experimental
group reported lower intensity during bleaching than those in
the placebo group (MannWhitney U test, p=0.032).
For all patients included in this clinical trial, the teeth with
most complaints of TS were the lateral incisors (73.3 %),
which differed statistically from the canines and premolars
(chi-square test, p<0.05) but were similar to the central
incisors (Table 4).
Discussion
As has been previously reported in several studies [5, 14, 24],
the results of the present study indicate that the application of a
2 % sodium fluoride and 5 % potassium nitrate desensitizing
agent does not interfere with the bleaching efficacy of 35 %
hydrogen peroxide, as it does not seem to affect the transenamel and transdentinal diffusion of hydrogen peroxide due
to the low molecular weight of this oxidizing molecule [14,
24]. Both groups demonstrated similar and significant tooth
color enhancement when compared with the baseline values,
with a variation of four SGU, which is in agreement with a
previous study [6].
With respect to color stability, 6 months after bleaching, no
significant differences were detected between the groups and
there was also no significant color rebound, as was expected,
in agreement with other studies [3, 6, 38], considering that inoffice bleaching seems to achieve satisfactory results when
more than one session is performed [39]. It's worth mentioning that laboratory studies have shown that there was no
change in or compromise of restorations due to the use of
high-concentration peroxides when the factor time for applying the bleaching agent was respected [40, 41]. Future
Table 1 Means and standard deviations of shade guide units (Vita
Classical shade guide) at different assessment points for the two treatment
groups
Baseline
1 week after bleaching
6 months after bleaching
Placebo
Desensitizer
5.91.1aA
1.80.7aB
1.90.6aB
6.01.1aA
1.50.6aB
1.70.7aB
843
Table 2 Means and standard deviations of SGU (subjective evaluation) and E (objective evaluation) at different assessment points for the
two treatment groups
SGU
Placebo
E
Desensitizer Placebo
Overall proportion
(95 % CI)
Desensitizer
Control Experimental Overall
4.10.9a 4.40.9a
4.00.9a 4.40.9a
4.71.1A 4.20.8A
4.10.7A 4.21.3A
During bleaching
Up to 24-h postbleaching
Placebo
Desensitizer
1.5 (1/1.75)aA
2 (0/2)aA
0.5 (0/1)aB
1 (0.25/1)aA
Central incisors 8
Lateral incisors 11
Canines
4
Premolars
0
7
11
1
0
15
22
5
0
50.0 (33.266.9)
73.3 (55.685.8)
16.7 (7.333.6)
0 (00.11)
A
A
B
C
844
sensitivity was observed in the desensitizer group in comparison with the placebo group.
Due to action mechanism of potassium nitrate, it could be
speculated that although restored teeth are more susceptible to
penetration of the whitening agent, they also appeared to be
more permeable to the permeation of potassium nitrate. This
could perhaps explain lower intensity of sensitivity observed
in the desensitizer group, and this would confirm the satisfactory results obtained when it has been used as a desensitizing
agent associated with bleaching [5, 14, 27, 50].
Finally, we should point out an important study limitation.
Although the application of desensitizing agent reduced the
intensity of the TS in patients with composite resin restorations, this product cannot prevent the reversible histological
changes [43, 52] produced by the hydrogen peroxide. In this
context, it would be interesting to conduct investigations to
evaluate the use of different drugs capable to reduce the
oxidative stress in cells caused by the hydrogen peroxide such
as antioxidants, corticosteroids, or selective anti-inflammatory.
Conclusions
Although the application of desensitizer did not reduce the
prevalence of TS in patients with composite restorations, the
intensity of sensitivity was significantly reduced during inoffice bleaching which suggests that this protocol can minimize this common adverse effect. The application of desensitizer prior to bleaching did not affect the whitening outcome,
which was stable after 6 months of clinical evaluation.
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