Background: There is a lack of consensus regarding the superiority of the two vital bleaching methods. Aims: To compare the clinical efficacies of the two methods at home and in- office. Materials & Methods: Data was collected from PubMed, Embase, Cochrane, Lilacs, Scielo and BBO. Two independent researchers selected the articles, ie., only randomized clinical trials. Where there was no initial agreement, researchers reached a consensus. The search strategy initially yielded 483 titles. After the exclusion by titles, 408 articles remained and following the abstract-based evaluation, only 5 were subjected to further analysis. Results: The most of the authors did not find any statistically significant differences between at home and in-office bleaching procedures. Conclusion: Both the at home and in-office methods alone or in association are equally efficient when a 14 day protocol is used

Borges, Boniek Castillo Dutra

Cunha, Ana Gabriela Gama

Machado, Cláudia Tavares

Pinheiro, Fabio Henrique de Sá Leitão

Santos, Alex Jose Souza dos

Vasconcelos, Adriana Alcantara Meira de

English

Repositório Institucional da Universidade Federal do Rio Grande do Norte

ISSN 0975-8437                                                                                                  INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):1-4 
©INTERNATIONAL JOURNAL OF DENTAL CLINICS   VOLUME 3 ISSUE 2 APRIL - JUNE 2011                                                                             1 
 
 
Comparison of the clinical efficacy of at-home and in-office bleaching  
Ana Gabriela Gama Cunha, Adriana Alcantara Meira De Vasconcelos, Boniek Castillo Dutra Borges, Claudia 
Tavares Machado, Alex Jose Souza Dos Santos, Fabio Henrique De Sa Leitao Pinheiro  
Abstract 
Background: There is a lack of consensus regarding the superiority of the two v ital b leaching 
methods.  Aims : To  compare the clinical efficacies of the two  methods  at home and in- office. Materials & 
Methods: Data was collected from PubMed, Embase, Cochrane, Lilacs, Scielo and BBO. Two independent 
researchers selected the articles, ie., only randomized clinical trials. Where there was no initial agreement, 
researchers reached a consensus. The search strategy initially y ielded 483 titles. After the exclusion by 
titles, 408 articles remained and following the abstract-based evaluation, only 5 were subjected to further 
analysis. Results: The most of the authors did not find any statistically significant differences between at 
home and  in-office b leaching procedures. Conclusion:  Both the at home and  in-office methods alone or in 
association are equally efficient when a 14 day protocol is used.  
Key Words:  Dentistry;Operative Dentistry;Dental Bleaching 
Received on: 13/08/2010          Accepted on: 13/11/2010 
 
Introduction 
                 Dental bleaching is one of the most 
common cosmetic procedures performed. The 
two methods most frequently applied for such 
purpose are the in-office and at-home techniques 
both of which use hydrogen peroxide-based 
bleaching agents.(1-9) At present, however, there 
appears to be no consensus regarding which 
method is more efficient.(10-12)  The aim of this 
study was compare the clinical efficacies of the 
two methods at home and in- office. 
Materials and Methods 
A systematic literature search was 
performed in the fo llowing electronic databases: 
PubMed, Embase, Cochrane, Lilacs, Scielo and 
BBO. The search criteria included all articles 
available upto January 2009. Keywords and their 
corresponding synonyms in both English and 
Portuguese were used. The search strategy is 
described on Table 1. As expected, the number 
of articles gradually decreased as the search 
progressed. The search was stopped when the 
number of art icles was sufficiently reduced 
without the risk of leaving out relevant studies.  
Article titles were evaluated by two independent 
examiners (A.G.G.C. e A.A.M.V.). The articles 
were selected for further consideration if they 
satisfied the following inclusion criterion: 
Present in their title any word related to dental 
bleaching.  
Keywords Keyword combinations 
Search #1 (Dent / Odont) Search #5 (#1 , #2) 
Search #2 (Bleaching / Whitening / Clareamento /Branqueamento) Search #6 (#5 ,  #3) 
Search #3 (Home / At Home /At-Home /Office / In Office / In-Office / Caseiro / Consultorio) Search #7 (#6 ,  #4) 
Search #4 (Efficacy / Comparison /Effect / Effectiveness / Efficiency  / Eficacia /Comparaçao / Efeito /Eficiencia) 
Table 1. Search strategy sequence 
 
Isolated keywords 
Search Update #1 (bleaching / whitening) , dentistry , home , Office 
Search Update #1 (clareamento / branqueamento),odontologia , caseiro , consultorio 
Table 2. Strategy sequence in the search update 
 
BASES Search  #1 Search Update Search  #2 Search #3 Search #4 Search #5 Search #6 Search  #7 
BBO 20.875 0 303 611 3.468 302 48 * 
Cochrane 46 0 8 * * * * * 
Embase 422.849 1 7.372 174.120 4.554.631 1.164 206 133 
Lilacs 43.427 0 370 8.887 41.364 272 46 * 
PubMed 479.147 2 5.461 180.716 2.778.858 1.793 393 181 
Scielo 8.094 0 101 1.144 23.378 29 * - 
Table 3. Final search result by database. (Total number of titles after searches in all databases   485     *A search was not necessary ) 
 
  
ORIGINAL RESEARCH ARTICLE 
ISSN 0975-8437                                                                                                  INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):1-4 
©INTERNATIONAL JOURNAL OF DENTAL CLINICS   VOLUME 3 ISSUE 2 APRIL - JUNE 2011                                                                             2 
 Auschill 2005(16) Bizhang 2009(15) Bernardon 2010 (14) Kugel  1997 (18)
 
Zekonis2003
 
(17) 
B
le
ac
h
in
g
 
m
et
h
o
d
 
A–At home 
(Strips) 
B–At home 
(Tray) 
C–In-office 
A–At home (Tray) 
B–In-office 
C-At home (Strips) 
 
A–In-office with light  +  at-
home  (Tray) 
B–In-office with light +  In-
office  Without luz 
C.1-In-office  with light  + At 
home (Tray) 
C.2   At home  (Tray) 
A-In-office +  
at- home  (Tray) 
B-In-office 
 
A At home 
(Tray) 
B–In-office 
B
le
ac
h
in
g
 a
g
en
t A-PH** 53%   
Strips 
B-PC***10% at-
home 
C-PH**38%  In-
office 
A-PC***10% at-
home 
B-PH**15% In-
office 
C-PH** 6% Fitas 
A-PH**35%in-office with 
light+PC***10% at-home 
B-PH**35% In-office with light 
+ PH**35% In-office with light 
C-1PH**35%In-office with light 
+ PC***10% at -home 
C.2PC***10% at- home 
A-PC*** 35% In-
office +PC*** 15% 
at-home 
B-PC*** 35% In-
office 
 
A-PC*** 10% 
At-home 
B-PH** 35% 
In-office 
T
ra
d
em
ar
k
 n
am
e
 
A-Whitestrips 
B-Opalescense 
PF 
C-Opalescense 
Xtra Boost  
A-Illumine, Home, 
Dentsply  
B-Illumine, Office, 
Dentsply 
C-blend-a-med 
white strips, Procter 
& Gamble 
A-PH**Whiteness HP maxx, 
FGM + PC*** Whiteness 
Perfect, FGM 
B-PH**Whiteness HP maxx, 
FGM + PH**Whiteness HP 
maxx, FGM 
C.1 PH** Whiteness HP maxx, 
FGM + PC***Whiteness 
Perfect, FGM 
C.2PC***Whiteness Perfect, 
FGM 
A-Rembrandt 
accelerate bleaching 
system + Quik Start + 
Rembrandt Gel Plus 
B- Rembrandt Quik 
Start  
A-Opalescense 
Tooth Whitening 
Gel 
B-tarBrite 
 
S
tu
d
y
 d
u
ra
ti
o
n
 
A-30 min, 2x/d, 
during 16 days 
B-8 h at night, 
during 7 days 
C-15 min, single 
application (1day) 
A–8hrs at night 
during 2 weeks 
B-45min, 1x / week 
during 3 weeks 
C-2 30min/day 
applications during 
2 weeks 
A-PH** (Three  15min 
applications / appointment 
during 2weeks) +   PC***( 8hrs 
at night during 2 weeks) 
B-PH(Three  15 min 
applications/appointment during 
2 weeks)  +  PH(Three  15 min 
applications / appointment 
during 2 weeks) ) 
C.1 PH** (Three 15min 
applications       / appointment 
during 2 weeks) + PC*** 
(8h at night, during 2 weeks) 
C.2  PC***( 8h at night, during 2 
weeks) 
A–In-office: 15 
min/week, during 2 
weeks At home: 1h, 
2x/d, during 5 days 
B-15 min/week, 
during 2 weeks 
A –2 weeks 
B–Two 30min 
applications/week 
during 2 weeks 
E
v
al
u
at
io
n
 
m
et
h
o
d
s 
Photographs + 
“Vita” Scale 
Colorímeter + 
“Vita” Scale 
Spectrophotometer +  “Vita” 
Scale 
Photographs +  “Vita” 
Scale + Level of 
patient acceptance 
Photographs 
+ “Trubyte Scale 
Bioform Color 
Ordered” + 
Colorímeter 
R
es
u
lt
s 
No bstatistically 
significant 
differences 
between groups. 
At home bleaching 
(trays) eand in-
office bleaching. 
Same clinical 
efficacy. At home 
bleaching showed 
(strips) inferior 
results. 
At home bleaching = In-office 
bleaching =  Association at 
home/ in-office bleaching 
Association at home/ 
in-office bleaching 
was more efficient 
At home 
bleaching is 
better than in-
office bleaching 
Table 4. Bleaching protocols, evaluation methods and results    **Hydrogen Peroxide ***Carbamide Peroxide 
An exclusion criterion was the lack of 
relevance to the object of study proposed such as 
for example, trad itional literature reviews, pilot 
studies, case reports, as well as, studies on non-
vital bleaching or that used whitening 
toothpastes. At the end of this stage 483 t itles 
were selected. The level of inter examiner 
agreement was determined by calculating the 
Kappa coefficient and was found to be “very 
good” (0.997), according to the classification 
proposed by Altman (1991).(13) 
When selection disagreements occurred, 
they were discussed until a consensus was 
reached regarding the tit les that were to be 
maintained (408 art icles). The same procedure 
was used to eliminate art icles based on their 
abstracts. In addition, at this stage, animal 
studies and studies in vitro were also eliminated. 
Remaining, thus for the further analysis were  
ISSN 0975-8437                                                                                                  INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):1-4 
©INTERNATIONAL JOURNAL OF DENTAL CLINICS   VOLUME 3 ISSUE 2 APRIL - JUNE 2011                                                                             3 
Criteria Auschill (16)  Bernardon (14) Bizhang (15) Kugel  (18)
 
Zekonis (17) 
Group sample size 13 15 30 10 10 
Sample calculation? Unknown Unknown Unknown Unknown Unknown 
Random selection? Yes Yes Yes Yes Yes 
Report of dropout rates? No No No No No 
Ausência de erro de 
“performance”? 
Yes Yes Yes Yes Yes 
Adequate statistical test? Partially* Yes Yes Yes Unknown 
Blind study? Yes Yes Yes Yes Yes 
Split  mouth study? No No No No Yes 
Risk of error? Medium Low Low Low Medium 
*the author performed two statistical tests but only one was adequate for the purpose of the study. 
Table 5. Quality assessment of the articles selected. 
only randomized controlled clinical trials  studies 
where either the sample size was smaller than 10. 
The studies where there were no control groups 
were also excluded. Four articles remained, one of 
which was in duplicate. Thus, at the end, only three 
full-text  articles thought to be relevant to the object 
of the study were analyzed by both examiners. In  
January 2010 complementary search updates were 
performed before submission of this systematic 
review for publication. In all databases, a 
simplified search strategy was used (Table 2). This 
was done to make future updates more practical. A 
second motive was to investigate whether search 
#4 was not excessively limit ing. In Pubmed and 
Embase, only  words in English were used, whereas 
in the other databases words in Portuguese were 
also utilized. In PubMed, nine art icles were found 
but only two met the inclusion criteria.(14, 15) In  
Embase, only one article arose and it was one of 
the articles already selected from the Pubmed 
search. Searches in the other databases did not 
yield additional articles. 
Results 
The final result of the search strategy 
implemented is presented on Table 3. The full-text  
articles considered for analysis were those 
produced in the search column before the asterisks, 
as well as, those raised in the search update. The 
bleaching protocols performed in  the articles 
selected, the evaluation methods utilized and the 
results are detailed on Table 4.  
Auschill et al. (16), Bernardon et al. (14) 
and  Bizhang et al.(15) were not reported any 
statistically  significant differences between the two  
groups in regard to efficacy of whitening (Table 4). 
Only Zekonis et al.(17)
 
observed that at-home 
bleaching is more efficient than the in-office 
method (Table 4). In Kugel et al.(18) it was shown 
that the association of the at-home / in-office 
methods is more efficient than the in-office 
technique alone (Table 4).  
Quality assessment of the five articles 
selected was based on the Cochrane Collaboration 
criteria.(Table 5) The fulfillment of five or more 
quality criterions corresponds to a low risk of error, 
three or more to a medium risk and less than three 
were of high risk. 
Discussion 
           Using a systematic review approach the 
present study evaluated two methods of dental 
bleaching: the at-home and in-office methods. The 
small number of studies analyzed was due to the 
rigorous inclusion criteria established in which 
only randomized controlled clin ical trials were 
selected (RCCT’s). Th is, of course, increases the 
strength of the results.(19, 20) According to the 
Cochrane Collaboration quality criteria the studies 
by Bernardon et al.(14), Bizhang et al.(15) and 
Kugel et al.(18) have low risk of error, i.e . very 
high level quality studies (Table 5).  
The findings of this systematic rev iew 
appear to break the paradigm that in-office 
bleaching is more efficient than the at-home 
modality.  Bernardon et al.(14) and Bizhang et al 
(15) observed that there were no statistically 
significant differences between the two methods.  
Kugel et al.(18), on the other hand, showed that the 
association of the two techniques is more efficient 
than in-office bleaching alone. This makes us 
question whether the super valorization o f in-office 
bleaching is not just a reflex of market ing 
campaigns promoted by the dental industry.  
A positive aspect of the use of at home 
bleaching is the reduction of time in the dental 
office, which reduces operational costs  and 
appears, in fact, to be an  advantage. However, it  
must be pointed out that the need for patient 
collaboration is a disadvantage that must be 
considered since, the 14-day minimum at home 
protocol appears to be the most efficient. 
Conclusion 
                 It was concluded that during the first 
week of treatment both the in-office technique and 
the association in-office / at-home bleaching were 
more efficient than the at-home method alone. 
However, after 14 days the efficiencies of the three 
protocols (at-home, in-office or association at-
home / in-office) were equivalent. 
 
ISSN 0975-8437                                                                                                  INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(2):1-4 
©INTERNATIONAL JOURNAL OF DENTAL CLINICS   VOLUME 3 ISSUE 2 APRIL - JUNE 2011                                                                             4 
Authors Affiliations: 1. Ana Gabriela Gama Cunha, 2. 
Adriana Alcantara Meira de Vasconcelos, Graduate 
Student, Masters of Science Program, Potiguar 
University School of Dentistry, 3. Boniek Castillo Dutra 
Borges, Research Fellow, 4. Claudia Tavares Machado, 
5. Alex Jose Souza dos Santos, 5. Fabio Henrique de Sa 
Leitao Pinheiro, Professor, Postgraduate Dentistry 
Program, Potiguar University School of  Dentistry, 
Natal, Brazil. 
 
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Address for Correspondence 
Boniek Castillo Dutra Borges 
R Minas Novas, 390, cs 18 
Zip-code: 59.088-725 
Natal-RN, Brazil 
Phone/fax number: 55 84 3234 5121 
E-mail: boniek.castillo@gmail.com 
Source of Support: Nil, Conflict of Interest: None Declared 
 


Comparison of the clinical efficacy of at-home and in-office bleaching

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Comparison of the clinical efficacy of at-home and in-office bleaching

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