Clinical Oral Investigations

, Volume 14, Issue 1, pp 1–10 | Cite as

Undesirable and adverse effects of tooth-whitening products: a review

  • Michel GoldbergEmail author
  • Martin Grootveld
  • Edward Lynch


Hydrogen peroxide (H2O2) is a powerful oxidising agent. It gives rise to agents known to be effective bleaching agents. The mechanisms of bleaching involve the degradation of the extracellular matrix and oxidation of chromophores located within enamel and dentin. However, H2O2 produces also local undesirable effects on tooth structures and oral mucosa. In clinical conditions, the daily low-level doses used to produce tooth whitening never generate general acute and sub-acute toxic effects. Genotoxicity and carcinogenicity only occur at concentrations that are never reached during dental treatments. Some transient adverse effects have been reported on the oral mucosa and the digestive tract if the product is swallowed. Local effects may occur on the oral mucosa and dental tissues during whitening, namely, pulp sensitivity, cervical resorption, release of selected components of dental restorative materials, and alteration of the enamel surface. Most of the local effects are dependent of the technique and concentration of the product so far used, but as the results of bleaching obtained are not stable, repeated treatments add to the adverse effects. The informed decision to administer or not and the control of bleaching effects should stand in the hand of dental surgeons and certainly not as it appears at present, as cosmetics sold without any restriction despite the potential health hazards of peroxides.


Tooth whitening Hydrogen peroxide Cytotoxic effects Genotoxicity Carcinogenicity Resorptions Hypersensitivity Enamel surface 


Conflicts of interest

We have no conflict of interest.


  1. 1.
    Abbot C (1918) Bleaching of discolored teeth by means of 30% perhydrol and electric light rays. J Allied Dent Soc 13:259Google Scholar
  2. 2.
    Abu-Sharkra A, Zeiger E (1990) Effects of salmonella genotypes and testing protocols on H2O2-induced mutation. Mutagenesis 5:469–471CrossRefGoogle Scholar
  3. 3.
    Albuquerque RC, Gomez RS, Dutra RA, Vasconcellos WA, Gomez RS, Gomez MV (2002) Effects of a 10% carbamide peroxide bleaching agent on rat oral epithelium proliferation. Braz Dent J 13:162–165CrossRefGoogle Scholar
  4. 4.
    Al-Salehi SK (2009) Effects of bleaching on mercury ion release from dental amalgam. J Dent Res 88:239–243PubMedGoogle Scholar
  5. 5.
    Anderson DG, Chiego DJ, Glickman GN, McCauley LK (1999) Clinical assessment of the effects of 10% carbamide peroxide gel on human pulp tissue. J Endod 25:247–250CrossRefPubMedGoogle Scholar
  6. 6.
    Anitua E, Zabalegui B, Gil J, Gascon F (1990) Internal bleaching of severe tetracycline discoloration: four year clinical evaluation. Quintessence Int 21:783–788PubMedGoogle Scholar
  7. 7.
    Aren G (2003) In vitro effects of bleaching agents on FM3A cell line. Quintessence Int 34:361–365PubMedGoogle Scholar
  8. 8.
    Arends J, Jongebloed WL, Schuthof J (1984) Interaction of urea and human enamel. Caries Res 18:17–24CrossRefPubMedGoogle Scholar
  9. 9.
    Attin T, Paquè F, Ajam F, Lennon M (2003) Review of the current status of tooth whitening with the walking bleach technique. Int Endod J 36:313–329CrossRefPubMedGoogle Scholar
  10. 10.
    Attin T, Hanning C, Wiegand A, Attin R (2004) Effects of bleaching on restorative materials and restorations—a systematic review. Dent Mater 20:852–861CrossRefPubMedGoogle Scholar
  11. 11.
    Aushill TM, Hellwig E, Schmidale S, Sculean A, Arweiler NB (2005) Efficacity, side effects and patients’ acceptance of different bleaching techniques (OTC, in-office, at-home). Oper Dent 30:156–163Google Scholar
  12. 12.
    Ben-Amar A, Liberman R, Gorfil C, Bernstein Y (1995) Effect of mouthguard bleaching on enamel surface. Am J Dent 8:29–32PubMedGoogle Scholar
  13. 13.
    Bock FG, Myers HK, Fox HW (1975) Cocarcinogenic activity of peroxy compounds. J Natl Cancer Inst 55:1359–1361PubMedGoogle Scholar
  14. 14.
    Brännström M (1968) Physio-pathological aspects of dentinal and pulpal response to irritants. In: Symons NBB (ed) Dentine and pulp. University of Dundee, Dundee, pp 231–246Google Scholar
  15. 15.
    Byers M, Dong WK (1983) Autoradiographic location of sensory nerve endings in dentin of monkey teeth. Anat Rec 205:441–454CrossRefPubMedGoogle Scholar
  16. 16.
    Cadenaro M, Breschi L, Antonioili F, Mazzoni A, Di Lenarda R (2006) Influence of whitening on the degree of conversion of dental adhesives on dentin. Eur J Oral Sci 114:257–262CrossRefPubMedGoogle Scholar
  17. 17.
    Chen HP, Chang CH, Chuang SF, Yang JY (2008) Effect of fluoride containing bleaching agents on enamel surface properties. J Dent 36:718–725CrossRefPubMedGoogle Scholar
  18. 18.
    Chiesara E, Dayan AD, Duschner H, Maier H, White DJ (2002) The safety of tooth whitening, Chap. 4. Blackwell Munksgaard, Oxford, pp 31–39Google Scholar
  19. 19.
    Christensen GJ (2005) Are snow-white teeth really so desirable? JADA 136:933–935PubMedGoogle Scholar
  20. 20.
    Cohen SC, Chase C (1979) Human pulpal response to bleaching procedures on vital teeth. J Endod 5:134–138CrossRefPubMedGoogle Scholar
  21. 21.
    Dahl JE, Becher R (1995) Acute toxicity of carbamide peroxide and a commercially available tooth-bleaching agent in rats. J Dent Res 74:710–714CrossRefPubMedGoogle Scholar
  22. 22.
    Dahl JE, Pallesen U (2003) Tooth bleaching—a critical review of the biological aspects. Crit Rev Oral Biol Med 14:292–304CrossRefPubMedGoogle Scholar
  23. 23.
    Desesso JM, Lavin AL, Hsia SM, Mavis RD (2000) Assessment of the carcinogenicity associated with oral exposures to hydrogen peroxide. Food Chem Toxicol 38:1021–1041CrossRefPubMedGoogle Scholar
  24. 24.
    Efeoglu N, Wood DJ, Efeoglu C (2007) Thirty-five percent carbamide peroxide application causes in vitro demineralization of enamel. Dent Mater 23:900–904CrossRefPubMedGoogle Scholar
  25. 25.
    Far C, Ruse ND (2003) Effect of bleaching on fracture toughness of composite-dentin bonds. J Adhes Dent 5:175–182PubMedGoogle Scholar
  26. 26.
    Friedman S, Rotstein I, Libfelt H, Stabholz A, Heiling I (1988) Incidence of external root resorption and esthetic results in 58 bleached pulpless teeth. Endod Dent Traumatol 4:23–26CrossRefPubMedGoogle Scholar
  27. 27.
    Fu B, Hoth-Hannig W, Hannig M (2007) Topic of micro-morphologic alterations: effects of dental bleaching on micro and nano-morphological alterations of the enamel surface. Am J Dent 20:35–40PubMedGoogle Scholar
  28. 28.
    Gökay O, Yilmaz F, Akin S, Tunçbilek M, Ertan R (2000) Penetration of the pulp chamber by bleaching agents in teeth restored with various restorative materials. J Endod 26:92–94CrossRefPubMedGoogle Scholar
  29. 29.
    Gökay O, Müjdeci A, Algin E (2004) Peroxide penetration into the pulp from whitening strips. J Endod 30:887–889CrossRefPubMedGoogle Scholar
  30. 30.
    Gökay O, Müjdeci A, Algin E (2005) In vitro peroxide penetration into the pulp chamber from newer bleaching products. Int Endod J 38:516–520CrossRefPubMedGoogle Scholar
  31. 31.
    Goldberg M, Arends J, Jongebloed W, Schuthof J, Septier D (1983) Action of urea solutions on human enamel surfaces. Caries Res 17:106–112CrossRefPubMedGoogle Scholar
  32. 32.
    Goldberg M, Arends J, Jongebloed WL, Schuthof J, Septier D, Apap M (1984) Action of urea solutions on unerupted and erupted teeth: an investigation on late maturation of human enamel. Gerodontology 3:191–195CrossRefPubMedGoogle Scholar
  33. 33.
    Gomez RS, de Castro Albuquerque R, Dutra RA, Vasconcellos WA, Reis DA, Gomez RS, Gomez MV (2002) Effects of a bleaching agent containing 35% carbamide peroxide on the immunolocalization of cyclin D and p16. J Oral Rehabil 29:906–909CrossRefPubMedGoogle Scholar
  34. 34.
    Guénal I, Sidoti-de Fraisse C, Gaumer S, Mignotte B (1997) Bcl-2 and Hsp27 act as different levels to suppress programmed cell death. Oncogene 15:347–360CrossRefPubMedGoogle Scholar
  35. 35.
    Hanks CT, Fat JC, Wataha JC, Corcoran JF (1993) Cytotoxicity and dentin permeability of carbamide peroxide and hydrogen peroxide vital bleaching materials, in vitro. J Dent Res 72:931–938PubMedGoogle Scholar
  36. 36.
    Hannig C, Zech R, Henze E, Dorr-Tolui R, Attin T (2003) Determination of peroxides in saliva—kinetics of peroxide release into saliva during home-bleaching with Whitestrips and Vivastyle. Arch Oral Biol 48:559–566CrossRefPubMedGoogle Scholar
  37. 37.
    Haywood VB, Houck VM, Heymann HO (1991) Nightguard vital bleaching: effects of various solutions on enamel surface texture and color. Quintessence Int 22:775–782Google Scholar
  38. 38.
    Haywood VB, Leonard RH, Nelson CF, Brunson WD (1994) Effectiveness, side effects and long term status of nightguard vital bleaching. J Am Dent Assoc 125:1219–1226PubMedGoogle Scholar
  39. 39.
    Hegedüs C, Bistey T, Flora-Nagy E, Keszthelyi G, Jenci A (1999) An atomic force microscopy study on the effect of bleaching agents on enamel surface. J Dent 27:509–515CrossRefPubMedGoogle Scholar
  40. 40.
    Heling I, Parson A, Rotstein I (1995) Effect of bleaching agents on dentin permeability to Streptococcus faecalis. J Endod 21:540–542CrossRefPubMedGoogle Scholar
  41. 41.
    Hermans N, Cos P, Maes L, De Bruyne T, Vanden Berghe D, Vlietinck AJ et al (2007) Challenges and pitfalls in antioxidant research. Curr Med Chem 14:417–430CrossRefPubMedGoogle Scholar
  42. 42.
    Holmstrup G, Palm AM, Lambjerg-Hansen H (1988) Bleaching of discoloured root-filled teeth. Endod Dent Traumatol 4:197–201CrossRefPubMedGoogle Scholar
  43. 43.
    Hosoya N, Honda K, Lino F, Arai T (2003) Changes in enamel surface roughness and adhesion of Streptococcus mutans to enamel after vital bleaching. J Dent 31:543–548CrossRefPubMedGoogle Scholar
  44. 44.
    International Agency on Research on Cancer (1999) Hydrogen peroxide. Monographs on the evaluation of carcinogenic risks to humans—re-evalaution of some organic chemicals, hydrazine and hydrogen paroxide, vol 71. IARC, Lyon, pp 671–689Google Scholar
  45. 45.
    Ito A, Watanabe H, Naito M, Naito Y (1981) Induction of duodenal tumors in mice by oral administration of hydrogen peroxide. Gann 72:174–175PubMedGoogle Scholar
  46. 46.
    Ito A, Naito M, Naito Y, Watanabe H (1982) Induction and characterization of gastro-duodenal lesions in mice given continuous oral administration of hydrogen peroxide. Gann 73:315–322PubMedGoogle Scholar
  47. 47.
    Ito A, Watanabe H, Naito M, Naito Y, Kawashima K (1984) Correlation between induction of duodenal tumor by hydrogen peroxide and catalase activity in mice. Gann 75:17–21PubMedGoogle Scholar
  48. 48.
    Jimmenez Rubio A, Segura JJ (1998) The effect of the bleaching agent sodium perborate on macrophage adhesion in vitro: implications in external cervical root resorption. J Endod 24:229–232CrossRefGoogle Scholar
  49. 49.
    Joiner A (2006) The bleaching of teeth: a review of the literature. J Dent 34:412–419CrossRefPubMedGoogle Scholar
  50. 50.
    Joiner A, Thakker G (2004) In vitro evaluation of a novel 6% hydrogen peroxide tooth whitening product. J Dent 32:19–25CrossRefPubMedGoogle Scholar
  51. 51.
    Joiner A, Thakker G, Cooper Y (2004) Evaluation of a 6% hydrogen peroxide tooth whitening gel on enamel and dentine microhardness in vitro. J Dent 32:27–34CrossRefPubMedGoogle Scholar
  52. 52.
    Klein-Szsanto AJP, Slaga TJ (1982) Effects of peroxidases on rodent skin: epidermal hyperplasia and tumor promotion. J Invest Dermatol 79:30–34CrossRefGoogle Scholar
  53. 53.
    Kruszewski M, Green MHL, Lowe JE, Szumiel I (1994) DNA strand breakage, cytotoxicity and mutagenicity of hydrogen peroxide treatment at 4°C and 37°C in L5178 Y sublines. Mutat Res 308:233–241PubMedGoogle Scholar
  54. 54.
    Leonard RH, Haywood VB, Phillips C (1997) Risk factors for developing tooth sensitivity and gingival irritation associated with nightguard vital bleaching. Quintessence Int 28:527–534PubMedGoogle Scholar
  55. 55.
    Leonard RH, Sharma A, Haywood VB (1998) Use of different concentrations of carbamide peroxide for bleaching teeth: an in vitro study. Quintessence Int 29:503–507PubMedGoogle Scholar
  56. 56.
    Leonard RH Jr, Smith LR, Garland GE, Caplan DJ (2004) Desensitizing agent efficacity during whitening in an at-risk population. J Esthet Restor Dent 16:49–55CrossRefPubMedGoogle Scholar
  57. 57.
    Li Y (1996) Biological properties of peroxide-containing tooth whiteners. Food Chem Toxicol 34:887–904CrossRefPubMedGoogle Scholar
  58. 58.
    Maeda T, Iwanaga T, Fujita T, Takahashi Y, Kobayashi S (1987) Distribution of nerve fibers immunoreactive to neurofilament protein in rat molars and periodontium. Cell Tissue Res 249:13–23CrossRefPubMedGoogle Scholar
  59. 59.
    Mair L, Joiner A (2004) The measurement of degradation and wear of three glass ionomers following peroxide bleaching. J Dent 32:41–45CrossRefPubMedGoogle Scholar
  60. 60.
    Markovic L, Jordan RA, Lakota N, Gaengler P (2007) Micromorphology of enamel surface after vital tooth bleaching. J Endod 33:607–610CrossRefPubMedGoogle Scholar
  61. 61.
    Martin JH, Bishop JG, Guentherman RH, Dorman HL (1968) Cellular response of gingival to prolonged application of dilute hydrogen peroxide. J Periodontol 39:208–210PubMedGoogle Scholar
  62. 62.
    McCraken MS, Haywood VB (1996) Demineralization effects of 10 per cent carbamide peroxide. J Dent 24:395–398CrossRefGoogle Scholar
  63. 63.
    Mor C, Steinberg D, Dogan H, Rotstein I (1998) Bacterial adherence to bleached surfaces of composite resin in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86:582–586CrossRefPubMedGoogle Scholar
  64. 64.
    Murchison DF, Charlton DG, Moore BK (1992) Carbamide peroxide bleaching: effects on enamel surface hardness and bonding. Oper Dent 17:181–185PubMedGoogle Scholar
  65. 65.
    Naik S, Tredwin CJ, Scully C (2005) Hydrogen peroxide tooth-whitening (bleaching): review of safety in relation to possible carcinogenesis. Oral Oncol 42:668–674CrossRefGoogle Scholar
  66. 66.
    Nutting E, Poe G (1963) A new combination for bleaching teeth. J South Calif Dent Assoc 128:289–291Google Scholar
  67. 67.
    Oda D, Nguyen MP, Royack GA, Tong DC (2001) H2O2 oxidative damage in cultured oral epithelial cells: the effect of shortterm. Vitamin C exposure. Anticancer Res 21(4A):2719–2724PubMedGoogle Scholar
  68. 68.
    Oltu Ü, Gürgan S (2000) Effects of three concentrations of carbamide peroxide on the structure of enamel. J Oral Rehabil 27:332–340CrossRefPubMedGoogle Scholar
  69. 69.
    Plotino G, Buono L, Grande NM, Pameijer CH, Somma F (2008) Nonvital tooth bleaching: a review of the literature and clinical procedures. J Endod 34:394–407CrossRefPubMedGoogle Scholar
  70. 70.
    Quirynen M, Bollen CM (1995) The influence of surface roughness and surface free-energy on supra- and sub-gingival plaque formation in man. A review of the literature. J Clin Periodontol 22:1–14PubMedGoogle Scholar
  71. 71.
    Radosevich CA, Weitzman SA (1989) Hydrogen peroxide induces squamous metaplasia in a hamster tracheal organ explant culture model. Carcinogenesis 10:1943–1946CrossRefPubMedGoogle Scholar
  72. 72.
    Robertello FJ, Dishman MV, Sarrett DC, Epperly AC (1999) Effect of home bleaching products on mercury release from an admixed amalgam. Am J Dent 12:227–230PubMedGoogle Scholar
  73. 73.
    Rodrigues JA, Basting RT, Serra MC, Rodrigues AL (2001) Effects of 10% carbamide peroxide bleaching materials on enamel microhardness. Am J Dent 14:67–71PubMedGoogle Scholar
  74. 74.
    Rotstein I, Torek Y, Misgav R (1991) Effect of cementum defects on radicular penetration of 30% H2O2 during intracoronal bleaching. J Endod 17:230–233CrossRefPubMedGoogle Scholar
  75. 75.
    Rotstein I, Mor C, Arwaz JR (1997) Changes in surface levels of mercury, silver, tin, and copper of dental amalgam treated with carbamide peroxide and hydrogen peroxide in vitro. Oral Surg Oral Med Oral Pathol Radiol Endod 83:506–509CrossRefGoogle Scholar
  76. 76.
    Rotstein I, Dogan H, Avron Y, Shemesh H, Steinberg D (2000) Mercury release from dental amalgam after treatment with 10% carbamide peroxide in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 89:216–219CrossRefPubMedGoogle Scholar
  77. 77.
    Ruse ND, Smith DC, Torneck CD, Tiltley KC (1990) Preliminary surface analysis of etched, bleached, and normal bovine enamel. J Dent Res 69:1610–1613PubMedGoogle Scholar
  78. 78.
    Schulte JR, Morrissette DB, Gasior EJ, Czajewski MV (1994) The effects of bleaching application time on dental pulp. J Am Dent Assoc 125:1330–1335PubMedGoogle Scholar
  79. 79.
    Seale NS, McIntosh JE, Taylor AN (1981) Pulpal reaction to bleaching of teeth in dogs. J Dent Res 60:948–953PubMedGoogle Scholar
  80. 80.
    Seghi RR, Denry I (1992) Effects of external bleaching on indentation and abrasion characteristics of human enamel in vitro. J Dent Res 71:1340–1344PubMedGoogle Scholar
  81. 81.
    Shannon H, Spencer P, Gross K, Tira D (1993) Characterization of enamel exposed to 10% carbamide peroxide bleaching agents. Quintessence Int 24:39–44PubMedGoogle Scholar
  82. 82.
    Sinensky MC, Leiser AL, Baqbish H (1995) Oxidative stress aspects of the cytotoxicity of carbamide peroxide: in vitro studies. Toxicol Lett 75:101–109CrossRefPubMedGoogle Scholar
  83. 83.
    Steinberg D, Blank O, Rotstein I (2003) Influence of dental biofilm on release of mercury from amalgam exposed to carbamide peroxide. J Biomed Mater Res 15:627–631CrossRefGoogle Scholar
  84. 84.
    Timblin CR, Janssen YWM, Mossman T (1995) Transcriptional activation of the proto-oncogen c-jun by asbestos and H2O2 is directly related to increased proliferation and transformation of tracheal epithelial cells. Cancer Res 55:2723–2726PubMedGoogle Scholar
  85. 85.
    Tredwin CJ, Naik S, Lewis NJ, Scully C (2006) Hydrogen peroxide tooth-whitening (bleaching) products: review of adverse effects and safety issues. Br Dent J 200:371–376CrossRefPubMedGoogle Scholar
  86. 86.
    Ulukapî H, Benderli Y, Ulukapi I (2003) Effect of pre- and postoperative bleaching on marginal leakage of amalgam and composite restaurations. Quintessence Int 34:505–508PubMedGoogle Scholar
  87. 87.
    Upham BL, Kang KS, Cho HY, Trosko JE (1997) Hydrogen peroxide inhibits gap junctional intercellular communication in glutathione sufficient but not in glutathione deficient cells. Carcinogenesis 18:37–42CrossRefPubMedGoogle Scholar
  88. 88.
    Watt BE, Proudfoot AT, Vale JA (2004) Hydrogen peroxide poisoning. Toxicol Rev 23:51–57CrossRefPubMedGoogle Scholar
  89. 89.
    Weitzman SA, Weitberg AB, Stossel TP, Schwartz J, Shklar G (1986) Effects of hydrogen peroxide on oral carcinogenesis in hamsters. J Periodontol 57:685–688PubMedGoogle Scholar
  90. 90.
    White DJ, Kozak KM, Zoladz JR, Duschner HJ, Götz H (2000) Effects of tooth-whitening gels on enamel and dentin ultrastructure—a confocal laser scanning microscopy pilot study. Compendium 21:S29–S34Google Scholar
  91. 91.
    White DJ, Kozak KM, Zoladz JR, Duschner HJ, Götz H (2002) Peroxide interaction with hard tissues: effects on surface hardness and surface/subsurface ultrastructural properties. Compendium 23:42–48PubMedGoogle Scholar
  92. 92.
    White DJ, Kozak K, Zoladz JR, Duschner HJ, Götz H (2003) Effects of Crest® Whitestrips™ bleaching on surface morphology and fracture susceptibility of teeth in vitro. J Clin Dent 14:82–87PubMedGoogle Scholar
  93. 93.
    Zantner C, Beheim-Schwarzbach N, Neumann K, Kielbassa AM (2007) Surface microhardness of enamel after different home bleaching procedures. Dent Mater 23:243–250CrossRefPubMedGoogle Scholar
  94. 94.
    Ziegler-Skylakakis K, Andrae U (1987) Mutagenicity of hydrogen peroxide in V79 Chinese hamster cells. Mutat Res 192:65–67CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Michel Goldberg
    • 1
    Email author
  • Martin Grootveld
    • 2
  • Edward Lynch
    • 3
  1. 1.EA2496, Faculté de Chirurgie DentaireUniversité Paris DescartesMontrougeFrance
  2. 2.Department of Applied ScienceLondon South Bank UniversityLondonUK
  3. 3.School of DentistryQueen’s UniversityBelfastIreland

Personalised recommendations