Clinical Oral Investigations

, Volume 23, Issue 10, pp 3673–3689 | Cite as

Are combined bleaching techniques better than their sole application? A systematic review and meta-analysis

  • Andres Felipe Millan Cardenas
  • Bianca Medeiros Maran
  • Lucila Cristina Rodrigues Araújo
  • Fabiana Suelen Figuerêdo de Siqueira
  • Letícia Maíra Wambier
  • Carla Castiglia Gonzaga
  • Alessandro D. LoguercioEmail author
  • Alessandra Reis



A systematic review and meta-analysis were performed to answer this research question: “Does combined in-office (IO) and at-home (AH) bleaching produce improved color change and lower tooth sensitivity (TS) better than solely AH or IO bleaching in adults?”

Material and methods

Randomized controlled trials in adults that compared combined versus sole application bleaching were included. The risk of bias (RoB) was evaluated using the Cochrane Collaboration tool. Meta-analyses were conducted for color change in shade guide units (∆SGU) and with a spectrophotometer (∆E*), risk, and intensity of TS, using the random effects model. Heterogeneity was assessed with Cochran’s Q test and I2 statistics. GRADE assessed the quality of the evidence. PubMed, Scopus, Web of Science, LILACS, BBO, Cochrane Library, SIGLE, IADR abstracts, unpublished, ongoing trial registries, dissertations, and theses were searched on August 28, 2017 (updated on January 29, 2019).


Twelve studies remained. Two were considered to have low RoB. For combined vs. IO bleaching, no significant difference for ∆E*, ∆SGU, and risk of TS were observed; data were not available to analyze the intensity of TS. For combined vs. AH bleaching, no significant difference for ∆E*, ∆SGU, but lower TS to risk (RR 1.40, 95% 1.10 to 1.80) and intensity (MD 1.40, 95% CI 0.18 to 2.63) were detected for AH bleaching. Quality of evidence was graded as low or very low in all meta-analyses.


Lower risk and intensity of TS was observed for the solely AH group without jeopardizing color change. However, more studies are still encouraged due to the low quality of evidence for most of the outcomes.

Clinical relevance

If clinicians are to choose between combined or sole AH bleaching, the solely AH may be preferable; combined bleaching may potentiate the risk of TS without benefits in color change. For combined or sole IO bleaching, no important clinical difference in color change and risk of TS were detected; however, intensity of TS could not be compared due to lack of data. Further studies should be conducted due to the low/very low quality of the evidence.


Tooth bleaching agents Tooth discolorations Dentin sensitivity Systematic review Meta-analysis 



This study was developed by Andres Felipe Millan Cardenas, Bianca Medeiros Maran, Lucila Cristina Rodrigues Araújo, Fabiana Suelen Figuerêdo de Siqueira, Letícia Maíra Wambier, and Carla Castiglia Gonzaga under the supervision of Profs. Alessandro Loguercio and Alessandra Reis. The authors would like to thank Prof. Ana Armas-Vega during the review process of meta-analysis.


This study was partially supported by National Council for Scientific and Technological Development from the Brazilian Government, under grants 303332/2017-4 and 305588/2014-1 and the Coordination of Improvement of Higher Level Personnel (CAPES) from the Brazilian Ministry of Education.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Sarrett DC (2002) Tooth whitening today. J Am Dent Assoc 133:1535–1538 quiz 1541CrossRefPubMedGoogle Scholar
  2. 2.
    Joiner A (2006) The bleaching of teeth: a review of the literature. J Dent 34:412–419. CrossRefPubMedGoogle Scholar
  3. 3.
    Auschill TM, Hellwig E, Schmidale S, Sculean A, Arweiler NB (2005) Efficacy, side-effects and patients’ acceptance of different bleaching techniques (OTC, in-office, at-home). Oper Dent 30(2):156–163. CrossRefPubMedGoogle Scholar
  4. 4.
    Meireles SS, Goettems ML, Dantas RV, Bona ÁD, Santos IS, Demarco FF (2014) Changes in oral health related quality of life after dental bleaching in a double-blind randomized clinical trial. J Dent 42(2):114–121. CrossRefPubMedGoogle Scholar
  5. 5.
    Samorodnitzky-Naveh GR, Grossmann Y, Bachner YG, Levin L (2010) Patients’ self-perception of tooth shade in relation to professionally objective evaluation. Quintessence Int 41:E80–E83PubMedGoogle Scholar
  6. 6.
    Haywood VB, Leonard RH, Nelson CF, Brunson WD (1994) Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 125:1219–1226CrossRefPubMedGoogle Scholar
  7. 7.
    Dahl JE, Pallesen U (2003) Tooth bleaching - a critical review of the biological aspects. Crit Rev Oral Biol Med 14:292–304CrossRefPubMedGoogle Scholar
  8. 8.
    Gallagher A, Maggio B, Bowman J, Borden L, Mason S, Felix H (2002) Clinical study to compare two in-office (chairside) whitening systems. J Clin Dent 13:219–224PubMedGoogle Scholar
  9. 9.
    Gurgan S, Cakir FY, Yazici E (2010) Different light-activated in-office bleaching systems: a clinical evaluation. Lasers Med Sci 25:817–822. CrossRefPubMedGoogle Scholar
  10. 10.
    Wetter NU, Branco EP, Deana AM, Pelino JE (2009) Color differences of canines and incisors in a comparative long-term clinical trial of three bleaching systems. Lasers Med Sci 24:941–947CrossRefPubMedGoogle Scholar
  11. 11.
    Rezende M, Siqueira SH, Kossatz S (2014) Clareamento dental - efeito da técnica sobre a sensibilidade dental e efetividade (Dental bleaching - technique effect on dental sensivity and effectiveness). Rev Assoc Paul Cir Dent 68:208–212Google Scholar
  12. 12.
    Mena-Serrano AP, Parreiras SO, do Nascimento EM, Borges CP, Berger SB, Loguercio AD, Reis A (2015) Effects of the concentration and composition of in-office bleaching gels on hydrogen peroxide penetration into the pulp chamber. Oper Dent 40:E76–E82. CrossRefPubMedGoogle Scholar
  13. 13.
    Soares DG, Basso FG, Hebling J, de Souza Costa CA (2015) Immediate and late analysis of dental pulp stem cells viability after indirect exposition to alternative in-office bleaching strategies. Clin Oral Investig 19:1013–1020. CrossRefPubMedGoogle Scholar
  14. 14.
    de Almeida LC, Soares DG, Gallinari MO, de Souza Costa CA, Dos Santos PH, Briso AL (2015) Color alteration, hydrogen peroxide diffusion, and cytotoxicity caused by in-office bleaching protocols. Clin Oral Investig 19:673–680. CrossRefPubMedGoogle Scholar
  15. 15.
    Rezende M, Chemin K, Vaez SC, Peixoto AC, de Freitas RJ, Braga SSL, Faria-e-Silva AL, da Silva GR, Soares CJ, Loguercio AD (2018) Effect of topical application of dipyrone on dental sensitivity reduction after in-office dental bleaching: a randomized, triple-blind multicenter clinical trial. J Am Dent Assoc 149(5):363–371. CrossRefPubMedGoogle Scholar
  16. 16.
    Dawson PF, Sharif MO, Smith AB, Brunton PA (2011) A clinical study comparing the efficacy and sensitivity of home vs combined whitening. Oper Dent 36(5):460–466. CrossRefPubMedGoogle Scholar
  17. 17.
    Deliperi S, Bardwell DN, Papathanasiou A (2004) Clinical evaluation of a combined in-office and take-home bleaching system. J Am Dent Assoc 135:628–634CrossRefPubMedGoogle Scholar
  18. 18.
    Matis BA, Cochran MA, Wang G, Eckert GJ (2009) A clinical evaluation of two in-office bleaching regimens with and without tray bleaching. Oper Dent 34:142–149. CrossRefPubMedGoogle Scholar
  19. 19.
    Buchalla W, Attin T (2007) External bleaching therapy with activation by heat, light or laser--a systematic review. Dent Mater 23:586–596. CrossRefPubMedGoogle Scholar
  20. 20.
    Rezende M, Ferri L, Kossatz S, Loguercio AD, Reis A (2016) Combined bleaching technique using low and high hydrogen peroxide in-office bleaching gel. Oper Dent 41:388–396. CrossRefPubMedGoogle Scholar
  21. 21.
    Bernardon JK, Sartori N, Ballarin A, Perdigao J, Lopes G, Baratieri LN (2010) Clinical performance of vital bleaching techniques. Oper Dent 35:3–10. CrossRefPubMedGoogle Scholar
  22. 22.
    Kugel G, Perry RD, Hoang E, Scherer W (1997) Effective tooth bleaching in 5 days: using a combined in-office and at-home bleaching system. Compend Contin Educ Dent 18(378):380–373Google Scholar
  23. 23.
    Zhao K, Zong L, Zhang Q, Att W (2013) Clinical comparison between two bleaching techniques: a 180-day follow-up study. Quintessence Int 44(8):601–607. CrossRefPubMedGoogle Scholar
  24. 24.
    Radz G (2014) Effectiveness of a combined in-office and take-home whitening system for teeth shades A3. 5 to A4. Compend Contin Educ Dent 35:696–700PubMedGoogle Scholar
  25. 25.
    Paula E, Kossatz S, Fernandes D, Loguercio A, Reis A (2013) The effect of perioperative ibuprofen use on tooth sensitivity caused by in-office bleaching. Oper Dent 38:601–608. CrossRefPubMedGoogle Scholar
  26. 26.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8:336–341. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Coban A, Can E, Soyman M (2011) Clinical evaluation of in office at home and combined bleaching. Paper presented at the IADR/AADR/CADR 89th General Session, San Diego, CaliforniaGoogle Scholar
  28. 28.
    Machado LS, Anchieta RB, dos Santos PH, Briso AL, Tovar N, Janal MN, Coelho PG, Sundfeld RH (2016) Clinical comparison of at-home and in-office dental bleaching procedures: a randomized trial of a split-mouth design. Int J Periodontics Restorative Dent 36:251–260. CrossRefPubMedGoogle Scholar
  29. 29.
    Rodrigues JL, Rocha PS, Pardim SLS, Machado ACV, Faria-e-Silva AL, Seraidarian PI (2018) Association between in-office and at-home tooth bleaching: a single blind randomized clinical trial. Braz Dent J 29:133–139CrossRefPubMedGoogle Scholar
  30. 30.
    Vochikovski L (2018) Sensibilidade dental e efetividade de um novo protocolo de aplicação da técnica de clareamento associado com aplicação de dessensibilizante. Dissertation, State University of Ponta Grossa, Ponta GrossaGoogle Scholar
  31. 31.
    de Souza Costa CA, Riehl H, Kina JF, Sacono NT, Hebling J (2010) Human pulp responses to in-office tooth bleaching. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109:e59–e64CrossRefGoogle Scholar
  32. 32.
    Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods G, Cochrane Statistical Methods G (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Franz-Montan M, Ramacciato JC, Rodrigues JA, Marchi GM, Rosalen PL, Groppo FC (2009) The effect of combined bleaching techniques on oral microbiota. Indian J Dent Res 20:304–307. CrossRefPubMedGoogle Scholar
  34. 34.
    Dias KRHC, Lima JP, Silva TM, Monte Alto RV, Oliveira Jr OB (2012) Evaluation of efficacy of three tooth bleaching technique. Paper presented at the IADR/AADR/CADR 89th General Session, San Diego, CaliforniaGoogle Scholar
  35. 35.
    Lima JP (2012) Avaliação clínico visual de três técnicas de clareamento dental. Universidade do Estado do Rio de JaneiroGoogle Scholar
  36. 36.
    Ma J, Liu W, Hunter A, Zhang W (2008) Performing meta-analysis with incomplete statistical information in clinical trials. BMC 8:56. CrossRefGoogle Scholar
  37. 37.
    Higgins J, Green S (2010) Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration. Accessed June 2019
  38. 38.
    Harris JD, Quatman CE, Manring MM, Siston RA, Flanigan DC (2014) How to write a systematic review. Am J Sports Med 42:2761–2768. CrossRefPubMedGoogle Scholar
  39. 39.
    Loguercio AD, Maran BM, Hanzen TA, Paula AMd, Perdigão J, Reis A (2017) Randomized clinical trials of dental bleaching – compliance with the CONSORT Statement: a systematic review. Braz Oral Res 31.
  40. 40.
    Schulz KF, Chalmers I, Hayes RJ, Altman DG (1995) Empirical evidence of bias. dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 273:408–412CrossRefPubMedGoogle Scholar
  41. 41.
    da Costa JB, McPharlin R, Paravina RD, Ferracane JL (2010) Comparison of at-home and in-office tooth whitening using a novel shade guide. Oper Dent 35:381–388. CrossRefPubMedGoogle Scholar
  42. 42.
    Giachetti L, Bertini F, Bambi C, Nieri M, Scaminaci Russo D (2010) A randomized clinical trial comparing at-home and in-office tooth whitening techniques: a nine-month follow-up. J Am Dent Assoc 141:1357–1364CrossRefPubMedGoogle Scholar
  43. 43.
    Moghadam FV, Majidinia S, Chasteen J, Ghavamnasiri M (2013) The degree of color change, rebound effect and sensitivity of bleached teeth associated with at-home and power bleaching techniques: a randomized clinical trial. Eur J Dent 7:405–411. CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Pintado-Palomino K, Peitl Filho O, Zanotto ED, Tirapelli C (2015) A clinical, randomized, controlled study on the use of desensitizing agents during tooth bleaching. J Dent 43:1099–1105. CrossRefPubMedGoogle Scholar
  45. 45.
    Kose C, Calixto AL, Bauer JR, Reis A, Loguercio AD (2016) Comparison of the effects of in-office bleaching times on whitening and tooth sensitivity: a single blind, randomized clinical trial. Oper Dent 41:138–145. CrossRefPubMedGoogle Scholar
  46. 46.
    Browning WD (2003) Use of shade guides for color measurement in tooth-bleaching studies. J Esthet Restor Dent 15:S13–S20CrossRefPubMedGoogle Scholar
  47. 47.
    Kihn PW, Barnes DM, Romberg E, Peterson K (2000) A clinical evaluation of 10 percent vs. 15 percent carbamide peroxide tooth-whitening agents. J Am Dent Assoc 131:1478–1484CrossRefPubMedGoogle Scholar
  48. 48.
    Chemin K, Rezende M, Loguercio AD, Reis A, Kossatz S (2018) Effectiveness of and dental sensitivity to at-home bleaching with 4% and 10% hydrogen peroxide: a randomized, triple-blind clinical trial. Oper Dent 43:232–240. CrossRefPubMedGoogle Scholar
  49. 49.
    Leonard RH Jr, Garland GE, Eagle JC, Caplan DJ (2002) Safety issues when using a 16% carbamide peroxide whitening solution. J Esthet Restor Dent 14:358–367CrossRefPubMedGoogle Scholar
  50. 50.
    Matis BA, Mousa HN, Cochran MA, Eckert GJ (2000) Clinical evaluation of bleaching agents of different concentrations. Quintessence Int 31:303–310PubMedGoogle Scholar
  51. 51.
    Luque-Martinez I, Reis A, Schroeder M, Munoz MA, Loguercio AD, Masterson D, Maia LC (2016) Comparison of efficacy of tray-delivered carbamide and hydrogen peroxide for at-home bleaching: a systematic review and meta-analysis. Clin Oral Investig 20:1419–1433. CrossRefPubMedGoogle Scholar
  52. 52.
    Matis B (2000) Degradation of gel in tray whitening. Compend Contin Educ Dent Suppl S28:S31–S25 quiz S49Google Scholar
  53. 53.
    Al-Qunaian T, Matis B, Cochran M (2003) In vivo kinetics of bleaching gel with three-percent hydrogen peroxide within the first hour. Oper Dent 28:236–241. CrossRefPubMedGoogle Scholar
  54. 54.
    Matis B, Yousef M, Cochran M, Eckert G (2002) Degradation of bleaching gels in vivo as a function of tray design and carbamide peroxide concentration. Oper Dent 27:12–18. CrossRefPubMedGoogle Scholar
  55. 55.
    Wang Y, Gao J, Jiang T, Liang S, Zhou Y, Matis BA (2015) Evaluation of the efficacy of potassium nitrate and sodium fluoride as desensitizing agents during tooth bleaching treatment - a systematic review and meta-analysis. J Dent 43:913–923. CrossRefPubMedGoogle Scholar
  56. 56.
    Cook S, McCleskey E (2002) Cell damage excites nociceptors through release of cytosolic ATP. Pain 95:41–47CrossRefPubMedGoogle Scholar
  57. 57.
    Rezende M, Loguercio AD, Kossatz S, Reis A (2016) Predictive factors on the efficacy and risk/intensity of tooth sensitivity of dental bleaching: a multi regression and logistic analysis. J Dent 45:1–6. CrossRefPubMedGoogle Scholar
  58. 58.
    Krause F, Jepsen S, Braun A (2008) Subjective intensities of pain and contentment with treatment outcomes during tray bleaching of vital teeth employing different carbamide peroxide concentrations. Quintessence Int 39:203–209PubMedGoogle Scholar
  59. 59.
    Kose C, Reis A, Baratieri LN, Loguercio AD (2011) Clinical effects of at-home bleaching along with desensitizing agent application. Am J Dent 24(6):379–382PubMedGoogle Scholar
  60. 60.
    Meireles SS, Heckmann SS, Santos IS, Della Bona A, Demarco FF (2008) A double blind randomized clinical trial of at-home tooth bleaching using two carbamide peroxide concentrations: 6-month follow-up. J Dent 36:878–884. CrossRefPubMedGoogle Scholar
  61. 61.
    Charakorn P, Cabanilla L, Wagner W, Foong W, Shaheen J, Pregitzer R, Schneider D (2009) The effect of preoperative ibuprofen on tooth sensitivity caused by in-office bleaching. Oper Dent 34:131–135. CrossRefPubMedGoogle Scholar
  62. 62.
    Marson FC, Sensi LG, Vieira LCC, Araujo E (2008) Clinical evaluation of in-off ice dental bleaching treatments with and without the use of light-activation sources. Oper Dent 33:15–22. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Andres Felipe Millan Cardenas
    • 1
  • Bianca Medeiros Maran
    • 2
    • 3
  • Lucila Cristina Rodrigues Araújo
    • 1
  • Fabiana Suelen Figuerêdo de Siqueira
    • 1
  • Letícia Maíra Wambier
    • 4
  • Carla Castiglia Gonzaga
    • 4
  • Alessandro D. Loguercio
    • 5
    • 6
    Email author
  • Alessandra Reis
    • 5
  1. 1.Postgraduate Program in DentistryCEUMA UniversitySão LuisBrazil
  2. 2.Department of Restorative DentistryState University of Western ParanáCascavelBrazil
  3. 3.Postgraduate Program in Dentistry, School of DentistryNorth Paraná UniversityLondrinaBrazil
  4. 4.Graduate Program in DentistryPositivo UniversityCuritibaBrazil
  5. 5.Department of Restorative DentistryState University of Ponta GrossaPonta GrossaBrazil
  6. 6.Escuela de la Salud Eugenio EspejoUniversidad UTEQuitoEcuador

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