Clinical Oral Investigations (2019) 23:2723–2732

https://doi.org/10.1007/s00784-018-2715-4

ORIGINAL ARTICLE

Effect of photobiomodulation with low-level laser therapy combined

with potassium nitrate on controlling post-bleaching tooth sensitivity:
clinical, randomized, controlled, double-blind, and split-mouth study
Brennda de Paula 1 & Cristiane Alencar 1 & Mariángela Ortiz 1 & Roberta Couto 1 & Jesuína Araújo 2 & Cecy Silva 1,3

Received: 28 May 2018 / Accepted: 17 October 2018 / Published online: 25 October 2018
# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Objectives To evaluate the effect of photobiomodulation with low-level laser therapy (PBM-LLLT) combined with 5% potas-
sium nitrate (KNO3) on controlling tooth sensitivity (TS) after in-office tooth bleaching.
Materials and methods Fifty volunteers were selected based on the inclusion and exclusion criteria and were randomly allocated
into four groups: G1 (control): placebo gel application, 35% hydrogen peroxide bleaching (HP35) and mock PBM-LLLT without
light emission; G2: placebo gel application, bleaching with HP35 and PBM-LLLT; G3: application of KNO3, bleaching with
HP35 and mock PBM-LLLT; and G4: application of KNO3, bleaching with HP35 and PBM-LLLT. A pain assessment ques-
tionnaire was used to evaluate TS during the 21 days of treatment. The Friedman test was used for intragroup analysis, and the
Wilcoxon and Mann-Whitney tests were used for intergroup comparisons.
Results The intragroup evaluation showed significant differences among the evaluation times in all groups (p ≤ 0.05). The
highest pain sensitivity levels were recorded on the 1st, 8th, and 15th days. In G1, TS manifested for up to 3 days after each
bleaching session, while G2, G3, and G4 presented TS only on the days of the bleaching sessions. Intergroup analysis showed
that TS manifestation differed significantly between G1 and the other groups (p ≤ 0.05) but did not differ significantly among G2,
G3, and G4 (p ≥ 0.05).
Conclusion PBM-LLLT and KNO3 are effective at reducing pain sensitivity after tooth bleaching, but no synergistic effect
between these treatments was observed for the different evaluation periods.
Clinical relevance The effect of PBM-LLLT combined with KNO3 on post-bleaching tooth sensitivity is similar to their individ-
ual use alone.

Keywords Tooth bleaching . Low-level laser therapy . Dentin desensitizers . Tooth sensitivity . Randomized clinical trial

Introduction break one or more double bonds of the organic chemical dyes
that stain the teeth.
Tooth bleaching plays an important role in cosmetic dentistry, Hard dental tissues are highly permeable to fluids, with
as a simple, less invasive, economical, and effective technique the greatest fluid flow in the interprismatic spaces and den-
[1, 2]. The mechanism of action of the bleaching agent is to tinal tubules [3]. Pigments located in the enamel and dentin
are broken down by reactive oxygen species (ROS) such as
hydroxyl radicals (OH−) and oxygen (O2) from bleaching
agents. Through oxide-reducing reactions, the pigmented
* Cecy Silva molecules are divided into smaller molecules, which ab-
cecymsilva@gmail.com sorb more light and diffuse from the dentin structure, pro-
moting a lighter tooth appearance [4]. However, the action
1
Graduate Program in Dentistry, Federal University of Pará, of hydrogen peroxide (HP) is not limited to the chromo-
Belém, PA, Brazil phores during diffusion; it also interacts with the tooth
2
School of Dentistry, Federal University of Pará, Belém, PA, Brazil structure [5].
3
Faculdade de Odontologia, Universidade Federal do Pará, Avenida Pulp injury has been reported to occur after tooth bleaching
Augusto Correa, no 1, Guamá, Belém, PA 66075-110, Brazil with 35% hydrogen peroxide (HP35), characterized by severe
2724
inflammation or necrosis during the first few days [6–9].
Studies of human teeth have identified responses similar to
those of previous studies using different HP concentrations
[10, 11]. Roderjan et al. [12] analyzed the human pulp re-
sponse of mandibular incisors before HP35 bleaching treat-
ment, and all experimental groups presented damaged pulp
tissue, with more than 60% of the whitened teeth exhibiting
signs of pulp necrosis.
Pulp cell contact with ROS generates oxidative stress,
which is at least partly due to an imbalance between the
amount of ROS and endogenous and exogenous antioxidants
[13]. This phenomenon can result in reduced cell viability, cell
membrane damage, proteolytic enzyme activation, and extra-
cellular matrix degradation [14–16]. In addition, inflammato-
ry mediators such as adenosine triphosphate, neuropeptides,
substance P33, and prostaglandins are released, which excite
or sensitize the nerve endings responsible for pain perception
[17–19]. This process triggers pulp tissue inflammation, caus-
ing tooth sensitivity (TS) [20]. Previous studies have reported
an incidence rate of 67–87% for TS after in-office bleaching
using high HP concentrations [21–24].
Thus, desensitizing therapies that act in the neuronal trans-
mission of pain stimuli and in the pulpal inflammatory re-
sponse are of great clinical importance. These agents are be-
lieved to reduce intradental nerve excitability [25]. Laser ther-
apy was recently presented as a treatment method to reduce
post-bleaching TS. The interaction of the laser with the tissue
causes different reactions depending on the active medium,
wavelength, intensity, and optical properties of the irradiated
tissue [26]. Studies suggest that low-level laser therapy (PBM-
LLLT) produces neuropharmacological effects such as the
synthesis, release, and metabolism of several endogenous ef-
fectors, including endorphins (β-endorphin) and bradykinin
[27]; acts on nerve cell action potentials by changing cell
membrane permeability and/or temporarily modifying senso-
ry axon endings [28]; affects the pain threshold [28, 29]; and
stimulates cellular function to result in less pulpal tissue injury
or inflammation following an external insult [30, 31].
Potassium nitrate (KNO3) has also been found to effectively
alleviate TS intensity after in-office bleaching [32, 33]. A recent
systematic review [33] evaluating 722 studies found that KNO3
reduced TS caused by tooth bleaching, but the findings were
inconsistent regarding changes in esthetic results with the use
of this desensitizing agent. KNO3 has a Bcalming^ effect on the
nerve by preventing subsequent repolarization after depolariza-
tion, thereby blocking the pain cycle [34].
Given that both KNO3 and PBM-LLLT present neurophar-
macological actions, the likely synergistic effect of their com-
bination would be beneficial; however, no previous clinical
trial has evaluated the use of KNO3 combined with PBM-
LLLT on post-bleaching sensitivity. Therefore, this random-
ized, controlled, double-blind, split-mouth clinical study in-
vestigated the effect of this combination on controlling pain
Clin Oral Invest (2019) 23:2723–2732
sensitivity after in-office bleaching. The null hypothesis is as
follows: H0 Postoperative sensitivity in the groups bleached
with the combined desensitizing treatments does not differ
from those treated with either PBM-LLLT or KNO3 alone in
the different evaluation periods.
Materials and methods
Ethical aspects
This randomized, controlled, double-blind, split-mouth
clinical study followed the recommendations of the
Consolidated Standards of Reporting Trials (CONSORT)
[35]. It was also submitted to the Ethics Committee for
Research with Human Beings of the Health Sciences
Institute of the Federal University of Pará (CEP-ICS/
UFPA) and was evaluated and approved under number
1,835,007 and registered on ClinicalTrials.gov under
identifier NCT03434782. All study participants provided
informed consent after being duly informed of the risks,
methods, and objectives of the study, in accordance with
the Declaration of Helsinki [36].
Sample size calculation
GPower 3.1 software (Heinrich-Heine-Universität,
Düsseldorf, Germany) was used to determine the sample size.
For this calculation, data were used from a previous pilot
study that followed the same methods. The calculation was
performed considering 80% statistical power, 5% α-error and
20% predicted loss to follow-up at the end of the study. The
resulting sample size calculated for this study was 25 patients
per group.
Study design
The study design is described in Fig. 1. After randomization,
patients were allocated into four groups based on the treatment
used (Table 1). The materials used in this study are described
in Table 2.
Sample selection
Patients ranged in age from 18 to 30 years old, and all
presented good oral health status (Table 3). Thus, patients
with caries, restoration, enamel hypoplasia, gingival reces-
sion, dentin exposure, visible cracks on buccal enamel,
pulpitis, or who had undergone endodontic treatment in
any of the six upper anterior teeth were excluded.
Participants who had undergone a previous bleaching pro-
cedure, presented prior tooth sensitivity, were under con-
tinuous use of anti-inflammatory or analgesic drugs,
Clin Oral Invest (2019) 23:2723–2732
Fig. 1 Study design and follow-
up
smoked, had parafunctional habits, were using oral remov-
able or fixed orthodontic appliances, of were pregnant or
breast-feeding were also excluded.
For patient selection, TS was checked through tactile
and evaporative stimulation. The tactile stimulus test was
performed by touching the exploratory probe in the shape
of a cross on the tooth surface in the apical to incisal and
mesial to distal directions. The evaporative stimulus test
was performed by applying an air jet at 40 psi using a
triple syringe for approximately 3 s, perpendicularly to the
vestibular surface of the tooth and 2 mm away from it.
The patient’s pain response was obtained per the pain
scores. Only volunteers with no recorded sensitivity to
the presented stimuli were included in the study.
2725
pH and salivary flow tests were also performed. To avoid
any interference with the results, participants were instructed
not to consume food or liquids 1 h before pH measurement.
Patients were instructed to chew pieces of orthodontic rubber
to mechanically stimulate saliva production, which they were
instructed not to swallow but to spit into a millimeter beaker.
The volume of saliva was recorded without considering the
foam that occasionally formed. The salivary flow for each
patient was calculated (ml/5 min). Subsequently, salivary pH
was measured using a previously calibrated pH meter (Oakton
WD-35619-10) per the manufacturer’s instructions. Patients
with salivary flow between 1 and 2 ml/min and pH between
6.5 and 7.0 were included in the study. All participants re-
ceived dental prophylaxis performed with a rubber cup and
2726 Clin Oral Invest (2019) 23:2723–2732

Table 1 Division of groups

Groups Desensitizing treatment before bleaching Bleaching treatment Laser therapy after bleaching

G1 (control) Placebo gel applied for 10 min Whiteness HP 35% FGM Placebo laser (tip only positioned on the tooth surface
without light emission)
G2 laser Placebo gel applied for 10 min Laser therapy—photon lase III DMC
G3 KNO3 KNO3 applied for 10 min Placebo laser (tip only positioned on the tooth surface
without light emission)
G4 KNO3+laser KNO3 applied for 10 min Laser therapy—photon lase III DMC

pumice stone 7 days prior to the start of the study. In addition,
the volunteers received oral hygiene kits with a standardized
toothpaste, which had no desensitizing action or fluoride, to
decrease possible interference with the study evaluation. The
kit contained a toothbrush (Oral B, Cerdas Indicator, São
Paulo, SP, Brazil) and toothpaste (My First Colgate®,
Colgate-Palmolive Company, SP, Brazil), and the volunteers
were instructed to use them three times daily.
Randomization
The randomization process was performed in two stages.
First, 50 volunteers were randomized and divided into two
groups of 25 patients. This randomization process was
performed using BioEstat 5.0 software (Sociedade Civil,
Mamirauá, Pará, Brazil), which used a computer-
generated random number table. In the second step, ran-
domization was performed by the principal researcher
through a numerical draw. The main objective of this sec-
ond randomization was to randomize the hemi-arch for
the split-mouth study design. Numbers 1 and 2 were
drawn for each volunteer within each large group accord-
ing to Fig. 1. Number 1 always corresponded to G1 or G3
and number 2 to G2 or G4. The first number drawn
corresponded to the right hemi-arch, and the not drawn
number corresponded to the opposite hemi-arch. Thus,
both volunteers and hemi-arches were randomized.
Blinding
For the double-blind study, the evaluator and patient were
blinded. A single evaluator, who was not involved in random-
ly allocating the patients and had no knowledge of the inter-
ventions applied in the groups, performed the pain sensitivity
analysis. Additionally, patients were unaware of what treat-
ment they received.
A single operator executed all experimental steps and was
knowledgeable of the interventions performed in each group.
In G1 and G3, the laser tip was positioned on the tooth surface,
but no laser was applied. The noise emitted by the laser equip-
ment during light emission was simulated for the patient using
a smartphone application (Voice Recorder HD—iPhone 7;
Apple®, Cupertino, California, USA). In G1 and G2, a place-
bo gel was also applied in the same manner as the
desensitizing KNO3 gel, per the manufacturer’s instructions.
The desensitizing and placebo gels were placed in identical
containers so that the patients could not identify which prod-
uct was being applied.
Treatment with 5% potassium nitrate
Prior to the bleaching treatment, the G3 and G4 subgroups
received KNO3 desensitizing gel application on the buccal
surfaces of their incisors, canines, and premolars using a
microbrush applicator (3 M ESPE, São Paulo, Brazil) for
10 min. A rubber cup (Microdont, São Paulo, Brazil) was then

Table 2 Description of the materials

Material Commercial name Manufacturer Composition

Hydrogen peroxide Whiteness HP FGM (Joinville, SC, Brasil) 35% hydrogen peroxide, thickener, red dye,
glycol and water
Potassium nitrate Desensibilize KF2% FGM (Joinville, SC, Brasil) Active ingredients: 5% potassium nitrate,
2% sodium fluoride
Non-fluoride My First Colgate® Colgate-Palmolive Company (São Paulo, SP, No active ingredient.
dentifrice Brasil)
Laser Photon Laser III DMC Equipments (São Carlos, SP, Brasil) Laser diode Arsenic Gallium and Aluminum
infrared (ArGaAl) with infrared wavelength
– 808 nm
Placebo gel K-Y® Johnson & Johnson (São Paulo, SP, Brasil) No active ingredient.
Clin Oral Invest (2019) 23:2723–2732 2727

Table 3 Demographic
characteristics G1 G2 G3 G4 p

Genre
Male n (%) 5 (20.83%) 5 (20.83%) 6 (29.16%) 6 (29.16%) 1.0000*
Female n (%) 18 (79.16%) 18 (79.16%) 16(70.83%) 16(70.83%)
Age
Mean (± standard 23.96 23.96 24.24 24.24 0.144**
deviation) (± 3.46) (± 3.46) (± 2.25) (± 2.25)
Confidence interval (95%) 22.57–25.34 22.57–25.34 23.34–25.14 23.34–25.14

*G test
**ANOVA test

mounted on a contra-angle hand-piece coupled to a and lower arches. After each bleaching session, the polished
micromotor at low speed (Kavo, Santa Catarina, Brazil) to surfaces were cleaned with a felt disc (Kota, São Paulo,
rub the desensitizing gel for 20 s onto each tooth, per the Brazil) and diamond paste (Diamond R, FGM, Joinville,
manufacturer’s specifications. Brazil).

Tooth bleaching Laser therapy

All groups received the in-office bleaching treatment after
application of the desensitizing or placebo gel. Prior to
bleaching, tooth prophylaxis was performed with a pumice
stone (Asfer, São Caetano do Sul, SP, Brazil). Next, a gingival
dam was prepared with the light-curing resin Top Dam (FGM,
Joinville, Brazil). Three 15-min applications of HP35 were
performed for a total of 45 min in each of the three sessions,
with a 7-day interval between each session, on the buccal
surface of the incisors, canines, and premolars of the upper
PBM-LLLT was performed after bleaching; therefore, G2 and
G4 received the laser application (therapeutic infrared Photon
Laser III, DMC, São Carlos, SP, Brazil) using infrared (IF)
light at 808 nm and arsenide-gallium-aluminum (AsGaAl)
active medium at two perpendicular points (located in the
apical and cervical region) on the buccal surface of the inci-
sors, canines, and premolars. The laser was operated in con-
tinuous mode; an energy of 1.7 J at a dose of 60 J/cm2 was
applied at each point for 16 s, with a spot size of 0.028 cm2.

Table 4 Median (M) and

interquartile deviation (ID) of the M (± ID)
sensitivity recorded in
questionnaire during 21 days of 1st week Groups 1st day 2nd day 3rd day 4th day 5th day 6th day 7th day
follow-up G1 2 (± 1)Aa 1 (± 1)Ab 1 (± 1)Ab 0 (± 0)Cc 0 (± 0)Cc 0 (± 0)Cc 0 (± 0)Cc
G2 1 (± 1)Ba 0 (± 0)Bb 0(± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
G3 1 (± 1)Ba 0 (± 1)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
G4 1 (± 1)Ba 0 (± 0)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
2nd week Groups 8th day 9th day 10th day 11th day 12th day 13th day 14th day
G1 3 (± 1)Da 2 (± 1)Ab 1 (± 2)Ab 0 (± 0)Cc 0 (± 0)Cc 0 (± 0)Cc 0 (± 0)Cc
G2 1 (± 2)Ba 0 (± 0)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
G3 1 (± 2)Ba 0 (± 1)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
G4 0 (± 1)Ba 0 (± 0)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
3nd week Groups 15th day 16th day 17th day 18th day 19th day 20th day 21st day
G1 3 (± 0)Da 2 (± 0)Ab 1 (± 1)Ab 0 (± 0) Cc 0 (± 0) Cc 0 (± 0)Cc 0 (± 0)Cc
G2 1 (± 2)Ba 0 (± 0)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
G3 1 (± 1)Bb 0 (± 1)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb
G4 0 (± 1)Bb 0 (± 0)Bb 0 (± 0)Bb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb 0 (± 0)Cb

Different capital letters represent significant statistical difference in the intergroup evaluation, for the different tests
applied; p ≤ 0.05
Different lowercase letters represent a significant statistical difference in the intragroup evaluation. Friedman’s
test; p ≤ 0.05
Pain scores: 0 = absent; 1 = smooth; 2 = moderate; 3 = severe
2728 Clin Oral Invest (2019) 23:2723–2732

The protocol used for the treatment of dental sensitivity was
recommended by the manufacturer of the laser equipment.
Sensitivity assessment
To evaluate each patient’s daily pain perception, responses
were recorded according to the following pain scores: absent
(0); mild (1); moderate (2); and severe (3). The sensitivity was
monitored for the 21 treatment days for the right and left
dental arches through a questionnaire. Pain was scored based
on personal perception of the pain threshold according to the
level of sensitivity or discomfort caused by the bleaching
treatment. The questionnaire was divided into teeth on the
right side and teeth on the left side.
males to females did not differ significantly (p = 0.144) among
the groups.
The median and interquartile deviations of the study
groups’ scores during the 21 days of clinical follow-up are
shown in Table 4. The Friedman test for intragroup analysis
showed a significant interaction between the time variables
(p ≤ 0.05), indicating higher pain sensitivity levels on
bleaching session days (1st, 8th, and 15th days). The inter-
group analysis results evaluated by the Wilcoxon and Mann-
Whitney tests for independent and dependent samples, respec-
tively, showed no significant differences in TS among groups
G2, G3, and G4 (p > 0.05); however, the G1 control group
differed significantly from the other groups (p < 0.05). The
p values for the different tests are shown in Table 5.

Statistical analysis
The sensitivity values reported by participants using the ques-
tionnaire during the 21-day follow-up period were entered into
an Excel worksheet (Microsoft Windows 2010) and analyzed
using BioEstat® 5.0 (Sociedade Civil Mamirauá, Pará,
Brazil). The Friedman test was used for intragroup analysis
and the Wilcoxon and Mann-Whitney tests were used for in-
tergroup evaluation of the dependent and independent sam-
ples, respectively. All analyses considered significance levels
of 5%.
Results
Forty-eight volunteers completed the study. The mean patient
age was similar among the study groups, and the proportion of
Discussion
To evaluate post-bleaching sensitivity, young patients with an
average age of 24 years old were selected to obtain a more
homogeneous sample. Volunteers over 30 years old were ex-
cluded from the study due to the physiological process of
continuous deposition of secondary dentin, which results in
decreased pulp volume, increased connective tissue within the
pulp and decreased innervation and vascularization [37, 38].
Highly heterogeneous samples may have introduced bias into
the study.
All study groups reported the highest sensitivity on the
days corresponding to the bleaching sessions. This result is
consistent with a previous clinical trial [31, 39]; however, the
control group in this trial had the highest TS level out of all
bleaching sessions, corroborating the results of a clinical trial

Table 5 p values of the different

tests applied at the same time Groups G1×G2 G1×G3 G1×G4 G2×G3 G2×G4 G3×G4

p value

1st week 1st day 0.0002 0.0008 0.0001 0.182 0.163 0.144
2nd day 0.0003 0.0004 0.0001 0.574 0.489 0.593
3rd day 0.0007 0.0008 0.0008 ns ns ns
4th–7th day ns ns ns ns ns ns
2nd week 1st day < 0.0001 0.0001 0.0008 0.089 0.152 0.159
2nd day 0.0001 0.0001 0.0001 0.693 0.833 0.685
3rd day 0.0033 0.0001 0.0001 ns ns ns
4th–7th day ns ns ns ns ns ns
3nd week 1st day < 0.0001 0.0001 0.0008 0.164 0.159 0.148
2nd day < 0.0001 0.0001 0.0001 0.722 0.543 0.685
3rd day < 0.0001 0.0001 0.0001 ns ns ns
4th–7th day ns ns ns ns ns ns

Friedman test for intragroup analysis, Wilcoxon and Mann-Whitney test for intergroup evaluation of dependent
and independent samples, respectively; p ≤ 0.05
ns there was no significant statistic difference
Clin Oral Invest (2019) 23:2723–2732
by Pintado-Palomino et al. [40]. During the treatment, TS
persisted up to 3 days after each bleaching session for G1,
evidencing the greater durability of these symptoms compared
with the other groups (p < 0.05). This is because HP and its
byproducts diffuse through the mineralized dental tissues,
reaching the pulp chamber [41] and inducing increased sub-
stance P expression, leading to neurogenic inflammation as a
response to vascular dilatation and an increased number of
infiltrating macrophages [42, 43].
A low-level AsGaAl diode laser with an IF light spectrum
was used in this study. IF irradiation shows good tissue pen-
etration and is an excellent wavelength for neural repairs due
to its ability to change biomembrane polarity [44]. In addition,
IF light causes high chromophore absorption in the pulp tissue
[45]. A split-mouth study design was chosen to aid in sample
selection; this methodology allows for a smaller sample size
[46]. On the other hand, the main limitation of the split-mouth
design is the risk of one treatment affecting the response to the
other treatment, which is known as the carry-across effect [46,
47]. However, laser is a coherent electromagnetic wave and
there is no consistent evidence that dental laser therapy can
produce any systemic effect. Many studies have shown the
promising effect of laser in the treatment of dentin sensitivity
[48–52] and others oral pain [53–55] using split-mouth
models. Thus, the carry-across effect was not considered a
limitation in the present study.
Statistical analysis showed that the group treated with
PBM-LLLT presented lower post-bleaching sensitivity than
the control group, corroborating the results of a clinical study
conducted by Moosavi et al. [39]. These authors evaluated the
effect of lasers of different wavelengths and observed that IF
irradiation from AsGaAl significantly effectively attenuated
the intensity of TS. This effect is explained by the neural
analgesic mechanism of PBM-LLLT, which is characterized
by an increased depolarization period for the C fibers. These
fibers are non-myelinated afferent pain receptors that transmit
chronic and secondary pain at 0.5–1 m per second. The polar-
ity is changed by reducing the cell membrane potential, there-
by blocking pain transmission [56].
KNO3 has been used in bleaching protocols because it
effectively reduces the intensity of TS without compromising
esthetic results [40]. The Wilcoxon test revealed that in the
group treated with this desensitizing agent, postoperative sen-
sitivity was significantly reduced compared with the control
group (p < 0.05), confirming the results of Thiesen et al. [32].
The efficacy of KNO3 treatment is caused by the diffusion of
potassium salts along the dentinal tubules. These salts act
directly on nociceptor cells, preventing them from responding
to excitatory stimuli due to the increased extracellular potas-
sium ion concentrations being sufficiently high to block action
potentials [57]. Peacock et al. [58] showed that potassium ion
concentrations above 0.08% around axons are necessary to
support nerve depolarization. In the 21 days of clinical
2729
follow-up, the KNO3 group presented mild sensitivity only
on days 1, 8, and 15, corresponding to the bleaching sessions.
This result can be explained by the high HP concentration in
the dental tissues during the bleaching session.
The product Desensibilize KF™ is formulated with 2%
sodium fluoride. Fluorine can chemically reduce and block
fluid movement in the dentinal tubules by forming calcium
and phosphorus precipitates, as well as calcium fluoride
(CaF2) and fluorapatite (FAp) [59, 60]. However, HP has a
low molecular weight (34.01 g/mol), which facilitates its pen-
etration into the interprismatic spaces of the enamel and den-
tinal tubules independently of the action of desensitizing
agents [61, 62]. KNO3 acts primarily on dental innervation
[25] rather than on dentin obliteration based on
Brannstrom’s hydrodynamic mechanism [63].
Combining PBM-LLLT with KNO3 significantly reduced
sensitivity after bleaching compared with the control group;
however, no significant difference was observed with the oth-
er desensitizing treatments; thus, the null hypothesis was ac-
cepted. TS relief was attributed to the increase in potassium
ions in the extracellular environment, which activated the
nerve endings in the pulp [64]; however, the potassium ion
concentration decreased as the physiological movement of the
dentin fluid increased, causing neural repolarization [65].
PBM-LLLT also acts on action potential generation by alter-
ing cytoplasmic membrane polarity. This treatment acts on
sodium-potassium (Na+ K+) channels and interferes with the
pain threshold [66]. Thus, although more potassium ions are
available in the extracellular medium, their concentration will
be dissipated by the increased speed of flow of the dentin fluid
between the tubules and dental pulp. This may explain the
non-enhanced analgesic effect from the PBM-LLLT with
KNO3 combination.
Pain is a multidimensional experience, consisting of moti-
vational, cognitive, affective, and discriminative components
[67]. Clinical measurements of pain intensity are generally
assessed subjectively, as in the present study, by the partici-
pant’s perception of their pain severity in response to the pre-
sented stimuli [68]. Although the pain scale is an instrument
with high validity and reliability [69], pain is an emotional
experience that may not be directly proportional to the stimu-
lus intensity and may lead to an inability to determine the
efficacy of a given treatment [70].
Conclusion
PBM-LLLT and KNO3 are effective at reducing pain sensitiv-
ity after tooth bleaching, but no synergistic effect between
these treatments was observed for the different evaluation pe-
riods. Both desensitizing agents evaluated reduced sensitivity
after bleaching with 35% hydrogen peroxide.
2730
Funding The work was supported by the National Council for Scientific
and Technological Development, Ministry of Science and Technology,
Brazil.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicts of
interest to disclose.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Declaration
of Helsinki and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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