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journal of dentistry xxx (2015) xxx–xxx
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1
2
3 Review
4 Evaluation of the efficacy of potassium nitrate and

5 sodium fluoride as desensitizing agents during
6 tooth bleaching treatment—A systematic review
7 and meta-analysis
8 Q1 Yining Wang a,1, Jinxia Gao a,1, Tao Jiang a, Shanshan Liang a, Yi Zhou a,*,
9 Bruce A. Matis b
a
10 Department of Prosthodontics, School and Hospital of Stomatology, Wuhan University, Wuhan, PR China
b
11 Indiana University School of Dentistry, Indianapolis, IN, USA
article info abstract
Article history: Objectives: This meta-analysis was performed to evaluate the efficacy of potassium nitrate
Received 23 November 2014 and sodium fluoride as desensitizing agents during tooth bleaching treatment.
Received in revised form Data, sources and study selection: An electronic systematic literature search was conducted in
12 March 2015 Cochrane Center Register of Controlled Trials, MEDLINE (PubMed) and EmBase in April, 2014
Accepted 27 March 2015 in English and without time restrictions. Study information extraction and methodological
Available online xxx quality assessments were accomplished by two reviewers independently. Methodological
quality was assessed by using the ‘‘Criteria for judging risk of bias in the ‘Risk of bias’
Keywords: assessment tool’’. Dichotomous data was summarized by odds ratio (OR) with 95% confi-
Hydrogen peroxide dence interval (CI) and continuous data was summarized by mean difference (MD) or
Carbamide peroxide standardised mean difference (SMD) with 95% confidence interval (CI). Statistical analyses
Tooth bleaching were carried out by using Review Manager 5.2.
In-office bleaching For evaluation of percent of patients experiencing tooth sensitivity (POTS), the pooled OR of
At-home bleaching desensitizers vs. placebo was 0.45 (95% CI: 0.28–0.73, P = 0.29). The pooled SMD of desensitizers
Tooth sensitivity vs. placebo was 0.47 (95% CI: 0.77 to 0.18, P = 0.13) in evaluation of level of tooth sensitivity
Desensitizing (LOTS). The results of shade evaluation remained inconsistent by evaluating subjective shade
Potassium nitrate guide unit difference (DSGU or SGU) and objective colour difference (DE).
Conclusions: This meta-analysis was performed to evaluate the efficacy of desensitizing
agents, potassium nitrate and sodium fluoride, for tooth bleaching treatments. Potassium Q2
nitrate and sodium fluoride reduce tooth sensitivity while no consistent conclusion of tooth
colour change was found.
# 2015 Published by Elsevier Ltd.
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12 13
15
* Corresponding author at: Department of Prosthodontics, School and Hospital of Stomatology, Wuhan University, 237# Luo Yu Road,
Wuhan 430079, PR China. Tel.: +86 27 87646696; fax: +86 27 87873260.
E-mail address: dryizhou@whu.edu.cn (Y. Zhou).
1
These authors contributed to the work equally and should be regarded as co-first authors.
http://dx.doi.org/10.1016/j.jdent.2015.03.015
0300-5712/# 2015 Published by Elsevier Ltd.
Please cite this article in press as: Wang Y, et al. Evaluation of the efficacy of potassium nitrate and sodium fluoride as desensitizing agents
during tooth bleaching treatment—A systematic review and meta-analysis. Journal of Dentistry (2015), http://dx.doi.org/10.1016/
j.jdent.2015.03.015
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2 journal of dentistry xxx (2015) xxx–xxx
16
17 1. Introduction tray during treatment. Other delivery systems can be used 75
independently by placing them into a subject’s mouth for a 76
18 Q3 Following improvement in the economy and in people’s living short time before bleaching is introduced.4,29–32 The mecha- 77
19 standards, an increasing number of people became self-aware nism of action of potassium nitrate remains unknown. Several 78
20 that teeth play an important role in their appearance. These randomized clinical trials have been published assessing the 79
21 patients with discoloured teeth demand whiter teeth and a safety and efficacy of tooth bleaching treatments. Some of 80
22 more aesthetically pleasing smile. According to a previous them conclude that desensitizers based on potassium nitrate 81
23 review, teeth whitening may be improved by physical or and sodium fluoride reduce tooth sensitivity.29,31–34 Others 82
24 chemical approaches.1 When comparing whitening tooth- question the efficacy of tooth bleaching when a desensitizing 83
25 pastes, professional cleaning, microabrasion of enamel with agent is used.4,30 The results of these studies are sometimes 84
26 abrasives and acid, resin-bonded composites, porcelain even conflicting, possibly because of the small number of 85
27 veneers and crowns, tooth bleaching was considered a more patients. Therefore the aim of this meta-analysis is to provide 86
28 accepted and conservative approach to improving the colour a more accurate estimate of the efficacy of two desensitizing 87
29 of teeth and a pleasant smile.1–6 The main chemical agents, potassium nitrate and sodium fluoride, during 88
30 approaches of tooth bleaching include at-home treatment, bleaching treatment. 89
31 in-office procedure and bleaching with over-the-counter (OTC)
32 bleaching products.7,8 For at-home tooth bleaching treatment, 90
33 10% carbamide peroxide (CP) delivered in a custom-fitting 2. Methods
34 mouth tray was introduced by Klusmier in late 1960s.9 This
35 successful technique was published by Haywood and Hey- All the work was performed by two reviewers, independently. 91
36 mann in 1989 and has become the gold-standard treatment in A discussion ensued if any disagreement occurred and 92
37 tooth whitening.9–12 Later the in-office procedure, of applying unresolved issues were solved by consulting a third reviewer. 93
38 a high concentration of hydrogen peroxide (HP) to tooth
39 bleaching with (or without) exposure to various kinds of heat 2.1. Inclusion criteria 94
40 or curing lights to enhance the effects became popular.8,11–15
41 Typically a 30–35% concentration of HP is used in vital and Clinical studies were included in this meta-analysis that 95
42 nonvital tooth bleaching during in-office procedures.11 Unlike satisfied the following inclusion criteria. Participants: patients 96
43 at-home bleaching techniques, in-office bleaching is super- with discoloured teeth (intrinsic discolouration and/or extrin- 97
44 vised by dentists. OTC products have increased in popularity sic discolouration) undergoing tooth bleaching treatment had 98
45 with patients and are self-administered. Different OTC to be randomized to test or control groups. The main 99
46 products have become available in markets, including approaches of tooth bleaching had to include at-home 100
47 whitening strips and gels, whitening rinses, paint-on gels treatments and/or in-office procedures. Interventions: desen- 101
48 with brushes, toothpastes, etc.1,8,16 The safety and efficacy of sitizer agents had to be based on potassium nitrate and/or 102
49 OTC products remain questionable.1,8,16,17 Evidence has sodium fluoride intervention products. Comparisons: control 103
50 shown that bleaching products based on CP and/or HP are products had to be placebo or other desensitizing agents. 104
51 relatively safe and effective when following manufacturer’s Outcomes: outcomes had to be arranged into two categories: 105
52 instructions.1,7,18 tooth sensitivity evaluation and shade evaluation. Studies 106
53 Nevertheless adverse effects are another concern often design: studies had to be designed as randomized controlled 107
54 expressed with bleaching.19–21 Many publications have voiced trials (RCT) or controlled clinical trials (CCT). 108
55 concerns about oral health and potential tooth structure
56 change after bleaching. Difficulty in dental hygiene, an 2.2. Exclusion criteria 109
57 unpleasant sensation in the mouth, gingival irritation, during
58 and postoperative tooth sensitivity, structural integrity of Clinical studies were excluded in this meta-analysis that 110
59 dental hard tissue and restoration are common risks reported contained the following criteria: (1) those estimating the 111
60 with tooth bleaching.20,22–24 Tooth sensitivity and/or gingival efficacy of over-the-counter (OTC) products which contained 112
61 irritation may be typical side effects associated with tooth desensitizing components, such as dentifrice, whitening 113
62 bleaching techniques.25 In previous reports, up to 66% of strips; (2) duplicate studies; (3) irrelevant studies; (4) in vitro 114
63 patients experienced side effects (tooth sensitivity and/or studies. 115
64 gingival irritation) after overnight vital bleaching.26 This kind
65 of discomfort is sometimes responsible for patients’ hesitancy 2.3. Search strategy and study selection 116
66 in tooth bleaching.
67 Modifications and improvements have been made to An electronic systematic literature search was conducted in 117
68 bleaching products. As compared with decreasing the con- Cochrane Center Register of Controlled Trials, MEDLINE (PubMed) 118
69 centration of peroxide products and administration of and EmBase in April, 2014 in English and without time 119
70 analgesic, the application of a desensitizing agent seemed restrictions. Additional studies were identified by searching 120
71 to be an effective option to reduce tooth sensitivity.27–29 reference lists of included studies and contacting experts. The 121
72 Potassium nitrate and sodium fluoride as desensitizers are medical subject headings (MeSH) and text words ‘‘hydrogen 122
73 used widely to treat tooth sensitivity. These agents may be peroxide’’, ‘‘carbamide peroxide’’, ‘‘whitening’’, ‘‘tooth whiten- 123
74 contained in bleaching gel and delivered by using a custom ing’’, ‘‘bleaching’’, ‘‘tooth bleaching’’, ‘‘brightening’’, ‘‘aesthetics’’, 124
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125 ‘‘in-office bleaching’’, ‘‘at-home bleaching’’, ‘‘tooth sensitivi- the heterogeneity was high and the P-value was lower than 181
126 ty’’, ‘‘hypersensitivity’’, ‘‘sensitivity’’ ‘‘desensitizing’’, ‘‘desen- 0.10, the DerSimonian and Laird random effects model was 182
127 sitizer’’, ‘‘desensitizing agent’’, ‘‘potassium nitrate’’, chosen for meta-analysis.38 183
128 ‘‘potassium nitrate–fluoride’’, ‘‘fluoride gel’’ were used and Sensitivity analysis was performed by sequentially exclud- 184
129 in combination with other strategies to identify RCTs or CCTs. ing some studies with high risk of bias in this review. 185
130 Initial scanning of the retrieved studies was conducted on Publication bias was investigated by use of Begg’s funnel 186
131 the basis of the titles and abstracts. The duplicated and plots, which through constructing a funnel plot and examin- 187
132 obviously irrelevant studies were removed. Full texts of ing its signs of asymmetry was able to determine whether the 188
133 potential interests were then scanned and only those meeting publication bias affected the validity of the estimates.39–41 The 189
134 inclusion criteria were included. signs of asymmetry in a funnel plot suggested the presence of 190
publication bias, but publication bias was not the only reason 191
135 2.4. Assessment of methodological quality and data for the asymmetry. Due to small number of included studies, 192
136 extraction the analysis of funnel plots and explanation of publication bias 193
would not be described any more. 194
137 Quality of retrieved studies was assessed by using the ‘‘Criteria Review Manager 5.2 (The Nordic Cochrane Centre, 195
138 for judging risk of bias in the ‘Risk of bias’ assessment tool’’. It Cochrane Collaboration) was used to carry out statistical 196
139 was a domain-based evaluation, which was neither a scale nor analyses. Thomson Reuters EndNote X7 as the reference 197
140 a checklist.35 In this assessment tool, random sequence manager was used to find and share research in this review. 198
141 generation, allocations concealment, blinding of participants
142 and personnel, blinding of outcome assessment, incomplete 199
143 outcome data, selective reporting and other bias were 3. Results
144 designed to appraise the methodological quality of included 200
145 studies. Bias was judged in each study as ‘‘low risk of bias’’, 3.1. Results of the search and selection of studies
146 ‘‘high risk of bias’’ and ‘‘unclear risk of bias’’. Low risks of bias
147 for each important outcome within and across studies were A total of seven hundred twenty two studies were identified 201
148 unlikely to seriously alter the results. While for the summary initially based on the search strategy. Two hundred fifty three 202
149 assessments of one or more unclear risk of bias, it would raise duplicated studies were removed by using the reference 203
150 some doubt about the results. In addition, the summary manager EndNote. Another four hundred forty seven obvi- 204
151 assessments for one or more of the high risk of bias would ously irrelevant studies were removed after scanning of the 205
152 seriously weaken confidence in the results. retrieved studies on the basis of the titles and abstracts. For 206
153 Extracted data included first author, year of publication, the twenty two studies of potential interests, eight studies 207
154 publication country, number of participants, desensitizing were not RCTs/CCTs,30,34,42–47 the desensitizers were GLUMA 208
155 agents, bleaching approach and material and outcome and VivaSens in two studies,48,49 one study was without 209
156 reporting. available data.50 It was worth mentioning that one study met 210
the inclusion criteria while the full-text could not be found 211
157 2.5. Statistical analysis through various ways. This study was not included in the 212
meta-analysis for no data could be abstracted.51 Ten studies 213
158 Statistical analysis was performed following the Cochrane were included in this review.4,29,31–33,52–56 A detailed flow chart 214
159 Handbook for Systematic Reviews of Interventions.35 of retrieval of studies is presented in Fig. 1. 215
160 A meta-analysis of RCTs or CCTs was conducted to
161 estimate the efficacy of desensitizer agents, potassium nitrate 3.2. Characteristics of the included studies 216
162 and sodium fluoride, for tooth bleaching treatment. Data type
163 for the outcome measurement included dichotomous data Detailed descriptions of the characteristics about the ten 217
164 and continuous data. Dichotomous data in percent of patients included studies are listed in Table 1. The studies included 218
165 experiencing tooth sensitivity (POTS) was summarized by were accomplished in Brazil, USA, Italy, Jordan and Spain. The 219
166 odds ratio (OR) with 95% confidence interval (CI). Continuous publication year of those studies range from 2004 to 2014. A 220
167 data in level of tooth sensitivity (LOTS), subjective shade guide total of three hundred ninety four patients were included in 221
168 unit difference (DSGU or SGU) and objective colour difference those ten studies and the sample size of each study ranged 222
169 (DE) were summarized by mean difference (MD) with a 95% CI. from 20 to 40 patients. Only one study was a multicentre trial 223
170 If the measurement instruments of the same outcome differed and contained ninety one patients.53 Carbamide peroxide (CP), 224
171 in those included studies, then standardized mean difference as the at-home bleaching agent, was used in five studies,31,52– 225
55
172 (SMD) was used instead of mean difference (MD). The while hydrogen peroxide (HP) was used as the agent with in- 226
173 heterogeneity across studies was tested by Cochran’s Q office bleaching in five studies.4,29,32,33,56 The percentage of 227
174 statistic and P-value. P-value lower than 0.10 is an indicator carbamide peroxide (CP) was 10% in three studies,31,53,55 16% in 228
175 of significant heterogeneity.36,37 In addition, I2 was used to one study,52 30% in one study.54 Four studies targeted 35% 229
176 estimate the degree of inconsistency of statistical analysis. hydrogen peroxide (HP) as the bleaching agent.29,32,33,56 One 230
177 The new quantity I2 was ranged from 0% to 100% and 25%, 50%, study used 28% hydrogen peroxide (HP).4 Potassium nitrate 231
178 75% represented low, moderate and high heterogeneity with sodium fluoride as the desensitizing agents were used in 232
179 respectively.37 Fixed effects model was used initially, assum- six studies.29,31–33,53,55 Two studies used only potassium 233
180 ing that all the included studies shared good homogeneity. If nitrate4,54 and two studies used only sodium fluoride52,56 as 234
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Fig. 1 – Flow chart of retrieve studies.
235 the desensitizer. The POTS, LOTS, DSGU or SGU and DE were Fig. 2. All of the items in one study were judged as ‘‘low risk of 245
236 reported in one or more in the included studies. Two studies bias’’,29 seven studies were judged as ‘‘unclear risk of 246
237 reported median and interquartiles ranges of LOTS. Data bias’’,31,52–54,56 and two studies were judged as ‘‘high risk of 247
238 conversion was not performed in this review due to the small bias’’.4,55 Fig. 3 illustrates the proportion of studies with each 248
239 sample size.29,32 The duration of intervention and follow-up of the judgements for each entry. The risk of bias of selective 249
240 varied between one week and six months. reporting was judged as ‘‘low’’, while random sequence 250
generation, allocations concealment, blinding of participants 251
241 3.3. Assessment of methodological quality and personnel, blinding of outcome assessment were judged 252
as ‘‘unclear’’. The risk of bias of incomplete outcome data and 253
242 The results of the methodological quality assessment of the other bias were judged as ‘‘high’’, however the proportion was 254
243 ten RCTs are presented in Figs. 2 and 3. All of the judgements in so small that it would not seriously weaken confidence in the 255
244 a cross-tabulation of the study by entry were presented in results. 256
Q6 Table 1 – Characteristics of the included studies.

Studies No. of Country Bleaching Desensitizer Bleaching Outcome Duration of
participants agent approach report follow-up time
Armenio (2008) Total: n = 30 Brazil 16% CP 1.23% SF HB LOTS; POTS;DSGU >7 weeks
Bonafe (2013) Total: n = 30 Brazil 35% HP 5% PN and 2% SF OB LOTS; POTS; DSGU; DE >6 months
Browning et al.53 Total: n = ? USA 10% CP Exp1:0.00% PN and HB POTS; SGU >13 weeks
0.00% SF
Exp2: 3.00% PN and
0.00% SF
Exp3: 0.50% PN and
0.00% SF
Exp4: 0.50% PN and
0.25% SF
Gallo et a.54 Total: n = 40 USA 30% CP 5% PN HB LOTS; SGU >10 days
Leonard et al.55 Total: n = 40 USA 10% CP 3% PN and 0.11% SF HB POTS >2 weeks
Maghaireh et al.56 Total: n = 51 Jordan 35% HP 2% SF OB LOTS; DSGU >2 weeks
Navarra (2013) Total: n = 20 Italy 10% CP PN and SF HB LOTS; DE 14 days
Pale (2013) Total: n = 32 Spain 28% HP 5% PN OB LOTS; DE >3 months
Reis et al.51 Total: n = 30 Brazil 35% HP 5% PN and 2% SF OB POTS; LOTS; DSGU >2 weeks
Tay et al.33 Total: n = 30 Brazil 35% HP 5% PN and 2% SF OB POTS; LOTS; DSGU >2 weeks
PN, potassium nitrate; SF, sodium fluoride; CP, carbamide peroxide; HP, hydrogen peroxide; HB, at-home bleaching; OB, in-office bleaching;
tooth sensitivity: POTS, percentage of patients with tooth sensitivity; LOTS, level of tooth sensitivity. Shade evaluation: DSGU (SGU), visual
subject methods; DE, instrumental object measurements.
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Fig. 2 – Risk of bias summary: judgements about each risk of bias item for each included study.
257
3.4. Meta-analysis ratio (OR) of desensitizers vs. placebo was 0.45 (95% CI: 0.28–0.73) 283
258 while the heterogeneity was I2 = 16% and P-value = 0.29. 284
3.4.1. Primary outcomes Statistical analysis in this group showed desensitizers significant 285
259 Tooth sensitivity evaluation includes POTS and LOTS. POTS in reducing the POTS during tooth bleaching treatment. 286
260 was determined at any time during or immediately after tooth The evaluation of LOTS is illustrated in Fig. 5. This meta- 287
261 bleaching (Fig. 4). LOTS was recorded by using a visual scale. analysis includes six studies. The pooled SMD of desensitizer 288
262 LOTS was evaluated during or up to 24 h after bleaching vs. placebo was 0.47 (95% CI: 0.77 to 0.18, P = 0.13). 289
263 (24 h) (Fig. 5). Statistical analysis in this group showed desensitizers were 290
significant in reducing the LOTS during or immediately after 291
264 3.4.2. Secondary outcomes tooth bleaching. 292
265 Shade evaluation includes DSGU (or SGU) and DE. Tooth colour The evaluation of DSGU (or SGU) at one week is illustrated 293
266 was evaluated visually by using Vita Classic Shade Guide or in Fig. 6. The result of pooled SMD of desensitizer vs. placebo 294
267 Trubyte Bioform Colour Ordered Shade Guide System. DSGU was 0.24 (95% CI: 0.03–0.46, P = 0.73) at one week after 295
268 represents the change in number of shade guide units (SGU) bleaching. Fig. 7 showed the pooled SMD of desensitizers vs. 296
269 (Figs. 6–8). Shade evaluation was also performed by object placebo was 0.34 (95% CI: 0.08–0.60, P = 0.36) two weeks after 297
270 measurements using a colorimeter or spectrophotometer. The bleaching. Statistical analysis showed desensitizers had a 298
271 evaluation of DSGU (or SGU) was performed at one week, two significant difference in changing tooth colour at one and two 299
272 weeks and seven weeks after tooth bleaching treatment, weeks after bleaching. Tooth colour change was bigger in 300
273 respectively. The colour system was based on the following experimental groups when compared to control groups. The 301
274 values: L*a*b*. In this system, L* represents the value from evaluation of DSGU (or SGU) at seven weeks after bleaching 302
275 black to white, a* represents the measurement along the red– was 0.14 (95% CI: 0.27 to 0.54, P = 0.06) (Fig. 8). Statistical 303
276 green axis and b* represents the measurement along the analysis in this group showed desensitizers had no significant 304
277 yellow–blue axis. A total colour difference between the two difference in changing tooth colour in the long term. 305
278 colours (DE) was calculated by using the formula: D The tooth shade evaluation of DE is illustrated in Fig. 9. This 306
279 E = ((DL*)2 + (Da*)2+(Db*)2)1/2 (Fig. 9).29,31 DE was recorded one meta-analysis included two studies. The SMD for DE was 0.03 307
280 week after tooth bleaching. (95% CI: 1.08 to 1.14, P = 0.05). Statistical analysis in this group 308
281 The evaluation of POTS is illustrated in Fig. 4. This meta- showed desensitizers had no significant difference in chang- 309
282 analysis includes six studies and eleven results. The pooled odds ing tooth colour at one week after bleaching. 310
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Fig. 3 – Risk of bias graph: judgements about each risk of bias item presented as percentages across all included studies.
311
3.5. Sensitivity analysis and publication bias more than one result.53 Another study also varied in data 315
type.29 The risk of bias was high in the third study.55 Outcome 316
312 Sensitivity analysis was performed in both tooth sensitivity of sensitivity analysis is illustrated in Table 2. When compared 317
313 and shade change evaluation by sequentially excluding three to the primary and secondary outcome, statistical analysis 318
314 studies.29,53,55 One study was a multi-centre trial and reported remained stable and reliable. 319
Fig. 4 – Forest plot of comparison: tooth sensitivity, outcome: POTS: percentage of patients with tooth sensitivity. POTS was
evaluated during or immediately after bleaching (=24 h).
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Fig. 5 – Forest plot of comparison: tooth sensitivity, outcome: LOTS: level of tooth sensitivity. LOTS was evaluated during or
immediately after bleaching (=24 h).
320 review, three RCTs were performed in USA and another four 328
4. Discussion RCTs were in Brazil; the results may be influenced by context 329
and culture. Potassium nitrate and sodium fluoride as 330
321 This is the first systematic literature review of RCTs or CCTs of intervention agents vary in concentration and categories of 331
322 desensitizer agents, potassium nitrate and sodium fluoride, in available studies. Carbamide peroxide or hydrogen peroxide is 332
323 the treatment of tooth bleaching. the main materials currently used in at-home or in-office 333
324 This meta-analysis of ten RCTs or CCTs has high internal bleaching process and they vary in concentration. Outcome 334
325 validity. But there are limitations when considering external reporting, duration of intervention and follow-up periods also 335
326 applicability. Limitations in the design and implementation of vary. In addition, the data was reported in percentage, which 336
327 some included studies suggest the likelihood of bias. In this was transformed to dichotomous data when considering POTS 337
Fig. 6 – Forest plot of comparison: visual shade guide unit evaluation: DSGU (or SGU). DSGU (or SGU) was evaluated one week
after bleaching.
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Fig. 7 – Forest plot of comparison: visual shade guide unit evaluation: DSGU (or SGU). DSGU (or SGU) was evaluated two
weeks after bleaching.
338 analysis in one study.53 Finally, though a comprehensive in available literature.2,57 This process may result in pulp 347
339 retrieval was conducted in the Cochrane Centre Register of inflammation and intradental nerve activity.58 About 50% of 348
340 Controlled Trials, MEDLINE (PubMed) and EmBase, there is a the patients experience sensitivity after bleaching, however 349
341 possibility of missing studies from other databases. These the mechanism of nociceptor activation is not well under- 350
342 potential limitations are likely to lower the confidence in the stood.59 Tooth sensitivity and pain related to bleaching should be 351
343 estimate of efficacy and safety of desensitizers. distinguished from dentine sensitivity. Investigators have 352
344 The mechanism of bleaching agents based on peroxide is hypothesized that some degree of pulpal inflammation may 353
345 not well known currently. Initial diffusion of peroxide through accompany bleaching sensitivity, which is different from the 354
346 enamel and dentine into the pulp chamber is well elucidated hydrodynamic theory in dentine sensitivity.22,60 Tooth bleaching 355
Fig. 8 – Forest plot of comparison: visual shade guide evaluation: DSGU (or SGU). DSGU (or SGU) was evaluated seven weeks
after bleaching.
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tooth bleaching based on using the same bleaching agent. The 382
result was that 0.5% potassium nitrate significantly reduced 383
the number of days participants experienced sensitivity while 384
3% potassium nitrate did not.53 A possible explanation may be 385
that 3% potassium nitrate created a higher osmotic gradient 386
than 0.5% potassium nitrate, which increased fluid flow 387
outward and stimulated the mechano-receptors and pain 388
rather than driving sufficient potassium ions inward to reduce 389
pain.53 However, most of the current studies aimed to evaluate 390
the efficacy of using potassium nitrate and/or sodium fluoride 391
in desensitizing agents based on sodium fluoride are rare.52 It 392
is worthy to mention that potassium nitrate with sodium 393
Fig. 9 – Forest plot of comparison: objective colour change
fluoride and potassium nitrate alone were usually applied 394
evaluation: DE. DE was evaluated one week after
before tooth bleaching while sodium fluoride was usually 395
bleaching.
applied only after patients experienced tooth sensitivity. 52 396
Sodium fluoride may inhibit demineralization by forming 397
a calcium fluoride layer on enamel. 66 The delivery method 398
356 may cause the release of cell-derived factors, such as ATP and of desensitizing agents was different in most of the 399
357 prostaglandins. This interaction may excite or sensitize pulpal included studies. Some studies applied desensitizing gel 400
358 nociceptors and result in pulp tissue damage.32 Hydrodynamics on the buccal surface of participant without disturbing it 401
359 of intradental nerve activation and neuropeptide release in for ten minutes. 29,32,33 Meanwhile desensitizing agents 402
360 response to this procedure is another hypothesis which is not were contained in the bleaching gel in some of the other 403
361 well understood currently.22,61 The exact mechanism of action of studies. 31,54 So the proper concentration, category and 404
362 potassium nitrate and sodium fluoride for reducing tooth delivery method of desensitizing agents should be inves- 405
363 sensitivity in the tooth bleaching process is not well understood. tigated in a future study. 406
364 It is likely that potassium ions are the active component and Some guidelines may be helpful in future research and 407
365 potassium nitrate works by reducing dentinal sensory nerve clinical procedures. First, clinicians should inform their 408
366 activity due to the depolarizing activity of the K+.34,62–64 On the patients about the advantages and possible adverse effects 409
367 other hand, fluoride treats tooth sensitivity probable by blocking of tooth bleaching.14 Second, it is necessary for clinicians to 410
368 exposed dentinal tubules or reducing the fluid flow into the pulp have a full understanding of indications and contraindications 411
369 and blocking transmission of stimuli.63,65 of tooth bleaching. For instance, patients with crack tooth 412
370 Some concern has been expressed about the efficacy of syndrome or who experience tooth sensitivity should be 413
371 desensitizing agents during tooth bleaching treatments. Some counselled when considering tooth bleaching.7 Third, con- 414
372 studies showed the use of potassium nitrate and/or sodium centration of bleaching agent and application duration may be 415
373 fluoride have reduced the intensity of tooth sensitivity. The the key factors in determining tooth bleaching efficacy. A 416
374 efficacy of tooth bleaching is not affected by this proce- higher concentration of peroxide containing products may 417
375 dure.29,34,52–54 Different results have been noted in other enhance the bleaching outcome and reduce the duration of 418
376 studies, where the percentage and level of tooth sensitivity application while side effects may also accompany this kind of 419
377 was similar in both desensitizing agents and placebo cells.51 procedure. Tooth sensitivity, tooth structure change are 420
378 The efficacy and safety of desensitizing agent in tooth potential adverse effects related to higher concentrations of 421
379 bleaching may relate to various factors; most of them remain peroxide contained products.67,68 In-office procedures with 422
380 unknown. A previous clinical investigation compared the higher concentration of peroxide containing products should 423
381 efficacy of 3% potassium nitrate and 0.5% potassium nitrate in be used with caution. 424
Table 2 – Tooth sensitivity analysis.

Outcome Excluded Studies Studies Participants Statistical method Effect estimate
POTS Bonafe (2013) 7 240 Odds ratio (M-H, fixed, 95% CI) 0.40 [0.22, 0.71]
Browning et al.53 8 249 Odds ratio (M-H, fixed, 95% CI) 0.33 [0.17, 0.62]
Leonard et al.55 10 320 Odds ratio (M-H, fixed, 95% CI) 0.51 [0.30, 0.86]
None 11 360 Odds ratio (M-H, fixed, 95% CI) 0.45 [0.28, 0.73]
(D)SGU1 Bonafe (2013) 8 274 Std. mean difference (IV, fixed, 95% CI) 0.31 [0.07, 0.55]
Browning et al.53 7 223 Std. mean difference (IV, fixed, 95% CI) 0.18 [ 0.08, 0.45]
None 10 334 Std. mean difference (IV, fixed, 95% CI) 0.24 [0.03, 0.46]
(D)SGU2 Browning et al.53 4 123 Std. mean difference (IV, fixed, 95% CI) 0.22 [ 0.14, 0.58]
None 7 234 Std. mean difference (IV, fixed, 95% CI) 0.34 [0.08, 0.60]
(D)SGU7 Bonafe (2013) 4 140 Std. mean difference (IV, random, 95% CI) 0.18 [ 0.39, 0.74]
Browning et al.53 3 89 Std. mean difference (IV, random, 95% CI) 0.33 [ 0.34, 1.00]
None 6 200 Std. mean difference (IV, random, 95% CI) 0.14 [ 0.27, 0.54]
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425 after dental bleaching in a double-blind randomized clinical 486

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4 Evaluation of the efficacy of potassium nitrate and

article info abstract

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Fig. 1 – Flow chart of retrieve studies.

Q6 Table 1 – Characteristics of the included studies.

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Table 2 – Tooth sensitivity analysis.

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