Create an evidence-grounded step-by-step dental clinical workflow for: In-Office Teeth Whitening. Include supported indications, contraindications, sequencing, decision points, and follow-up.

1. Introduction

Dental bleaching encompasses a range of techniques and concentrations of bleaching gel, with in-office treatments, at-home solutions, or a combination of both being the most prevalent and effective methods tailored to individual patient needs and staining severity [1,3,9,10]. While at-home tooth whitening involves the daily application of lower concentrations of carbamide peroxide (CP), in-office whitening employs higher concentrations of bleaching gels. The choice between these approaches hinges on treatment goals, patient preferences, and clinical considerations. In-office procedures typically produce faster and more noticeable results, often incorporating techniques like light activation. Conversely, at-home kits offer the convenience of home-based treatment and may be more cost-effective. Both approaches are generally safe when used as directed, with in-office treatments benefiting from professional supervision and customization. Decisions regarding the use of light activation should be made in consultation with a dental professional, considering individual patient factors and preferences, while prioritizing safety and efficacy [1,2,5,7].

Is a White Diet Necessary for Tooth Bleaching Procedures? A Systematic Review and Meta-Analysis. © 2024 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

4. Discussion

This systematic review highlights the multifaceted landscape of research in the field of dental whitening. The lack of homogeneity among in vitro studies underscores the need for standardized methodologies and consistent reporting practices. Furthermore, the lack of clinical trials with extended follow-up periods raises questions regarding the durability and long-term effects of various whitening interventions. Furthermore, the absence of studies specifically measuring the whiteness index of the teeth adds another layer of complexity to the existing body of literature. As the investigators navigate through these research gaps, it becomes imperative for future investigations to address these limitations, fostering a more comprehensive understanding of dental whitening practices and their implications. This will not only contribute to the scientific rigor of the field but also guide clinicians and researchers towards more informed and evidence-based approaches in the pursuit of achieving optimal dental aesthetics.

Is a White Diet Necessary for Tooth Bleaching Procedures? A Systematic Review and Meta-Analysis. © 2024 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

4. Discussion

Accordingly, a white diet is not the only factor that affects the maintenance of the bleaching treatment. Implementing maintenance by using professionally suggested home-care approaches is important. Indeed, some patients may opt to enhance and maintain their perfected tooth color after dental bleaching by returning once or twice a year for touch-up conservation protocols at the dental office. On the other hand, individuals who prefer home oral hygiene-based approaches may opt for powered toothbrushes, as this protocol has been shown to remove more stains and plaque compared to manual toothbrushes alone [70,71,72]. Other bleaching agents on the market include over-the-counter products such as bleaching toothpastes, strips, and mouthwashes [73]. These agents might be inadequate when compared to home-bleaching [74,75]. However, because of their stain removal capacity, they can be used as an alternative for color maintenance after whitening when monitored by a dental expert [76]. Moreover, fluoridated bleaching gels, nano-carbonate apatite, or fractional CO2 laser may support the post-bleaching maintenance effect by inducing the remineralization fluoride acquisition of the enamel, or preventing stain absorption [77,78,79].

Is a White Diet Necessary for Tooth Bleaching Procedures? A Systematic Review and Meta-Analysis. © 2024 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

1. Introduction

The number of people dissatisfied with their smiles has been growing in recent years, whether because of tooth color or nonanatomical alterations in enamel, such as hypomineralization defects [1], increasing the demand for esthetic procedures in the dental office among patients [2]. Consequently, tooth bleaching, either at home or in the office, has become an important requirement [3]. This treatment is based on the application of peroxide gels on the enamel surface of vital teeth, where hydrogen peroxide, through its oxidative process, cleaves the bonds of organic molecules (chromophores), thereby providing the tooth with a whiter structure [4].

Effect of Sodium Ascorbate, Grape Seed Extract, and Aloe Vera Application after In-Office Bleaching on the Bond Strength of Enamel: A 3-Year Evaluation. Copyright © 2023 Alexandra Mena-Serrano et al. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Introduction

Low/medium13 concentrations of bleaching gel (6-20%) have been developed by manufacturers with the intention to reduce the adverse effects of in-office dental bleaching. Recently, several clinical studies have shown excellent bleaching efficacy and fewer adverse effects when low concentrations of HP were used.2,12,13 These aspects appear particularly crucial in younger patients, such as adolescents. The most recommended technique for them thus far has been at-home bleaching due to its low concentration.14 This is especially relevant because adolescents typically have more permeable teeth given their maturation level.15 However, studies have indicated that adolescents encounter challenges in removing excess bleaching gel from trays and find them somewhat difficult to use,16 making low concentration in-office bleaching a good option to avoid this problem. In light of these findings, low-concentration in-office bleaching emerges as a viable option to address these issues.

In-office dental bleaching in adolescents using 6% hydrogen peroxide with and without gingival barrier: a randomized double-blind clinical trial. Carneiro TS, Favoreto MW, Rodrigues JPF, Sutil E, Centenaro GG, Freitas IM, Reis A, García LC, Loguercio AD. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Introduction

Adolescents are concerned about social acceptance and their emotional well-being and self-esteem can be improved by dental aesthetic procedures.1 Among them, dental bleaching is considered a less invasive technique with positive effects on these patients’ quality of life and aesthetic self-perception.2 Dental bleaching is very effective both in the case of intrinsic and extrinsic discolorations3,4,5 and can be done in various ways. In-office bleaching techniques that use high or medium concentrations of hydrogen peroxide (HP) (20% to 40%) provide faster results.6,7 However, several adverse effects have been observed, among which are tooth sensitivity and gingival irritation (GI).8

In-office dental bleaching in adolescents using 6% hydrogen peroxide with and without gingival barrier: a randomized double-blind clinical trial. Carneiro TS, Favoreto MW, Rodrigues JPF, Sutil E, Centenaro GG, Freitas IM, Reis A, García LC, Loguercio AD. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

3. Discussion

Masking the remaining darkened teeth is a hard task for the clinician and laboratory technician. The etiology of this darkening may help predict the degree of tissue response to the proposed interventions, such as bleaching procedures [31,32]. However, the degree to which this tooth will be exactly whitened at the end of the process cannot be defined [33,34]. In addition, recurrence of the initial color may present over the years, or even little prediction of the results [33], requiring frequent repairs required by picky patients. This fact contributed to choosing a definitive basis treatment in the case proposed, with the restoration in ceramic for masking the darkened substrate. However, non-invasive treatments should be prioritized before any definitive treatment aiming integrity of teeth; after unsuccessful outcomes, definitive treatments should be suggested with the patient’s agreement.

Partial Ceramic Veneer Technique for Challenging Esthetic Frontal Restorative Procedures. © 2023 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Introduction and background

External tooth bleaching is a safe procedure that allows tooth whitening to be retained for several years. In-office bleaching or chair-side techniques are entirely dependent on the dental professional. Almost all the techniques involve applying a hydrogen peroxide gel of concentrations ranging from 25% to 40% [2]. Patients should undergo scaling and polishing of the tooth surface before bleaching and a careful evaluation to determine the nature of the discoloration. Nevertheless, concerns have been raised with introducing external bleaching, mostly related to the caustic effects of free oxygen radicals that may cause tissue damage in oral soft and hard tissues [2].

Post-Operative Sensitivity and Color Change Due to In-Office Bleaching With the Prior Use of Different Desensitizing Agents: A Systematic Review. Copyright © 2022, Krishnakumar et al. Creative Commons Attribution 3.0 International (https://creativecommons.org/licenses/by/3.0/).

Review

Post-operative tooth sensitivity is a common problem experienced by patients after vital bleaching. Since the tooth bleaching procedure usually requires multiple sessions to achieve the required shade, sore tooth sensitivity experienced by the patients during the first visit could be a factor for patients to be discouraged from continuing the treatment [22-26]. Several studies have called attention to the role of desensitizing agents’ application in the management of post-operative tooth sensitivity in vital in-office bleaching procedures [22-31]. Since the concentration of the bleaching agent is considerably higher than in at-home bleaching procedures, the experience of post-operative tooth sensitivity is also higher [31], with a lack in more comparison studies. From the data available so far, it could be understood that the most effective mode of application of the desensitizing agent would be the application of the agents directly on the tooth surface before the in-office bleaching procedure [25,26].

Post-Operative Sensitivity and Color Change Due to In-Office Bleaching With the Prior Use of Different Desensitizing Agents: A Systematic Review. Copyright © 2022, Krishnakumar et al. Creative Commons Attribution 3.0 International (https://creativecommons.org/licenses/by/3.0/).