New Whitening Option for Patients With Heavy Stains

At-home bleaching effective on coffee, cigarette stains

May 15, 2012 -- At-home bleaching using 6% hydrogen peroxide is effective in removing stains caused by coffee or cigarette smoke, according to a new study in the Journal of the American Dental Association.

Extrinsic stains have a multifactorial etiology involving chromogens that are derived from dietary sources or pigmented substances that are used habitually in the mouth, noted the study authors, from Pontifical Catholic University of Paraná and Federal University of Paraná in Brazil (JADA, May 2012, Vol. 143:5, pp. e1-e7).

"Coffee, tea, red wine, orange juice, some soft drinks, and food colorants are considered staining agents that lead to extrinsic tooth discoloration when consumed frequently," they wrote.

However, the literature is limited with regard to data pertaining to the best choice and efficacy of stain-removal techniques, they noted.

40 enamel surfaces tested

To evaluate the stain-removal ability of tooth bleaching and simulated tooth brushing, and to determine enamel susceptibility to restaining, the researchers measured the baseline color of 40 bovine labial enamel surfaces by using a portable colorimeter with a 6-mm diameter tip.

The coffee solution was prepared by dissolving six grams of instant coffee powder in 300 milliliters of boiling water. The specimens were then immersed in the solution for 72 hours at 37°C.

The color readings were taken in accordance with the Commission Internationale de l'Eclairage L*a*b* system against a white background. The specimens were then divided in half and stained with coffee and cigarette smoke.

The other 20 specimens were exposed to a smoking machine that contained smoke from five cigarettes that were smoked to a length of 10 mm beyond the tipping paper that covers the filter. The jar was kept saturated for 10 minutes. The researches repeated this cycle three times.

After the staining procedures, the color measurements were taken again and compared to the color of the specimens at baseline. The specimens were then divided into two subgroups and subjected to at-home bleaching (one hour per day for 21 days) or simulated tooth brushing (120 cycles per day for 21 days), followed by another color measurement.

Both staining procedures were then repeated and another color measurement was taken.

Coffee enhances restraining potential

Here are some of the key results:

• The first color measurement showed that cigarette smoke and coffee staining resulted in similar discoloration (p > .05).
• At the second color measurement, tooth brushing resulted in a significant reduction in color change only for specimens stained with cigarette smoke (p < .001), whereas tooth bleaching resulted in significantly reduced values for specimens stained with cigarette smoke or coffee (p < .05).
• Restaining with cigarette smoke did not increase the color change significantly for specimens that underwent bleaching or toothbrushing (p > .05). In contrast, restaining with coffee resulted in significantly more discoloration for both groups of specimens, irrespective of the stain-removal method (p < .05).
• At the last color measurement, the coffee-stained specimens that underwent toothbrushing experienced the highest mean discoloration, with statistically significant differences between these specimens and the specimens that were stained with cigarette smoke (p < .05).

"The study results show that at-home bleaching removed both coffee and cigarette-smoke staining," the authors concluded. "The restaining potential was greater for specimens stained with coffee than for those stained with cigarette smoke, regardless of the removal method used."

A 2008 study (Brazilian Oral Research, Apr-Jun 2008, Vol. 22(2), pp.106-111) that evaluated the effectiveness of whitening dentifrices for the removal of extrinsic tooth stains had more mixed results. Researchers from the department of restorative dentistry at Vale do Paraíba University in Brazil examined the effect of distilled water, Colgate, Crest Extra Whitening, and Rapid White on specimens stained in a solution of black tea. They found that only the whitening dentifrice Rapid White was effective for the removal of extrinsic stains.

Meanwhile, a Procter & Gamble study presented at the 81st general session of the International Association for Dental Research in 2003 found that effective dentifrices remove extrinsic stains only, while effective bleaching technologies remove both extrinsic and intrinsic color sources.

Whitening Toothbrush Maker Responds to Criticism

J&J to Modify Some Toothbrush Whitening Claims

September 9, 2011 -- The National Advertising Division (NAD) of the Council of Better Business Bureaus has recommended that Johnson & Johnson Healthcare Products modify certain claims for its Reach Total Care + Whitening toothbrush to clarify that the brush whitens teeth through the abrasive action rather than through bleaching.

As part of its routine monitoring program, NAD -- the advertising industry's self-regulatory forum -- requested substantiation for express claims that included the following:

• "Ordinary toothbrushes clean teeth. Reach whitens them."
• "At the core of this revolutionary toothbrush Reach has engineered a unique row of bristles infused with calcium carbonate microwhitening technology. That means each time you brush, you're whitening teeth and removing stains.*" (*in lab tests)

NAD also examined the implied claim that the Reach Total Care + Whitening toothbrush has been proven to actually whiten teeth when used in the same manner as an ordinary toothbrush.

According to Johnson & Johnson, the toothbrush, launched in 2010, was designed with bristles embedded with calcium carbonate, recognized by the U.S. Food and Drug Administration as an abrasive used in fluoride toothpastes.

In support of its claims, Johnson & Johnson provided NAD with evidence that demonstrated that bristles infused with calcium carbonate do, in fact, provide statistically significantly better stain removal than brushes with ordinary bristles. The company also provided testing to demonstrate that its advertised toothbrush provided significantly better plaque removal than the other two ordinary toothbrushes tested. In addition, Johnson & Johnson's evidence demonstrated that the difference in whitening and stain removal was meaningful to consumers, according to NAD.

Following its review of evidence, NAD determined that Johnson & Johnson could support the claim that "[o]rdinary toothbrushes clean teeth. Reach whitens them."

However, NAD recommended that the company modify the claims "whitens and removes stains" and "each time you brush you're whitening and removing stains" to ensure that consumers are aware that stain removal is accomplished extrinsically, through the stain-removing abrasive action of the bristles, not intrinsically through bleaching.

According to NAD, Johnson & Johnson said it is disappointed with the NAD recommendation, "given the industry practice of making unqualified whitening claims based on data showing extrinsic whitening only. Nevertheless, we understand NAD's recommendations and will take them into consideration in future advertising."

      - Dr. Green's sidenote


Patients often ask me for product recommendations (the best toothpaste, toothbrush, etc.) that they can use at home.   We evaluate 100s of products every year to make these recommendations.  Johnson & Johnson is one of the leading manufacturers of these at-home products and to be fair, I will say that the vast majority of their products are excellent and safe.  By posting this article I am in no way suggesting to my readers that they should ban J&J products from their household.  The objective of this post is to educate my readers on the potential dangers of store-bought whitening products.
When I recommend any product to my patients, I always consider it's method of action (how it does what the manufacturer claims it does).  With whitening toothpaste or toothbrushes the method of action usually involves the removal of surface staining rather than through the whitening of the tooth enamel (which is how whitening solutions and gels work).  This is accomplished through the use of coarse abrasives, not whitening solutions.

The best analogy I can use would be to compare toothbrushing to sanding a piece of wood.  In order to take raw wood from being splintery and rough to a smooth surface that's ready to stain, a carpenter will start with a fairly coarse grit of sandpaper and use progressively finer grits until the board is smooth.  When you brush your teeth you are basically doing the same thing-you use a toothbrush and toothpaste containing a minty abrasive to remove the plaque and food debris from your teeth.  I always recommend the use of a soft or ultra-soft bristled toothbrush and a traditional toothpaste (non-whitening and non-tartar control) for my patients.  This will do more than enough to clean your teeth on a daily basis - without damaging or removing the protective enamel.  If you have issues with stain accumulation related to heavy coffee consumption, smoking or drinking colas or red wines, that's where we come in.

Regular visits to a dental hygienist are always essential to maintaining optimum dental health, especially if you accumulate stain easily! 

Whitening - How to Reduce Sensitivity & Damage to Your Teeth

Can Remineralizing Agents Mitigate Whitening Side Effects?

September 14, 2011 -- Teeth whitening is one of the most popular cosmetic procedures today, but it can have negative side effects. For example, some studies have reported that whitening agents containing carbamide peroxide or peroxide may soften dental hard tissues.

But a new study has found that adding a remineralizing agent such as casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) to the bleaching agent could mitigate this effect (Operative Dentistry, August 5, 2011).

"I decided to conduct this research since there is still a debate over whether carbamide peroxide- or peroxide-containing agents can soften dental hard tissues," said lead study author Boniek Castillo Dutra Borges, DDS, an assistant professor at the school of dentistry at Potiguar University, in a DrBicuspid.com interview. "We were surprised to find that the use of a CPP-ACP paste (MI Paste, GC America) with carbamide peroxide bleaching agents increased the bleached enamel's microhardness and did not have an influence on whitening efficacy."

“CPP-ACP-containing paste with carbamide peroxides could protect enamel against the demineralization. ...”
— Boniek Borges, DDS

Although a large body of scientific evidence demonstrates that CPP-ACP could promote the remineralization of even enamel subsurface caries lesions, this study is the first to analyze the effect of MI Paste in conjunction with carbamide peroxides on bleached enamel microhardness, the study authors noted.

To evaluate the efficacy of an at-home bleaching technique using 10% or 16% carbamide peroxide modified by CPP-ACP and its influence on the microhardness of bleached enamel, the researchers studied 40 bovine incisors that were stained using a mixture of red wine and tea.

The samples were divided into four groups of 10 each and stored in artificial saliva for a 14-day bleaching regimen. The four groups were bleached using the following:

• 10% carbamide peroxide only
• A blend of 10% carbamide peroxide and a CPP-ACP paste
• 16% carbamide peroxide only
• A blend of 16% carbamide peroxide and a CPP-ACP paste

For two of the 10% and 16% peroxide groups, the peroxides were mixed with MI Paste by combining 1 mL of the bleaching gels with 1 mL of MI Paste until a homogeneous paste was obtained, which was then inserted into a 5-mL syringe. In addition, the peroxides alone were put into 5-mL syringes.

The researchers assessed the microhardness and color of the teeth at baseline and immediately after the 14-day bleaching regimen using a microhardness tester and a spectrophotometer. The degree of color change was determined by the Commission Internationale de l'Eclariage (CIE) L*a*b* system and Vita shade guide parameters.

Among the study's findings:

• The teeth that were bleached with a blend of peroxide (10% or 16%) and the CPP-ACP paste presented increased microhardness values after the bleaching regimen compared with the baseline measurements, whereas the samples that were bleached with peroxide only did not show any differences in their microhardness values.
• All the bleaching agents were effective at whitening the teeth and did not show a statistically significant difference using the CIE L*a*b* system or the Vita shade guide parameters.

Even though the concentration of carbamide peroxides was reduced to half after mixing them with MI Paste, this was not sufficient to affect color change after a 14-day bleaching regimen, the authors wrote.

"The use of a casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)-containing paste with carbamide peroxides could protect enamel against the demineralization caused by these bleaching agents," Dr. Borges said. "This improves safety and might even reduce in vivo tooth sensitivity during the bleaching process."

The authors did note, however, that more studies are needed to evaluate how long this microhardness increase could last. Other bleaching peroxides should be tested in association with the CPP-ACP paste because the results of this study are not applicable to all types of bleaching systems, they added.