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Article history: Objective: To evaluate the influence of light on bleaching efficacy and tooth sensitivity
Received 24 October 2011 during in-office vital bleaching.
Received in revised form Data sources: We performed a literature search using Medline, EMBASE and Cochrane
11 April 2012 Central up to September 2011.
Accepted 14 April 2012 Study selection: All randomised controlled trials (RCTs) or quasi-RCTs comparing the light-
activated bleaching system with non-activation bleaching system were included. Reports
without clinical data concerning bleaching efficacy or tooth sensitivity were excluded.
Keywords: Results: Eleven studies were included in the meta-analysis. A light-activated system pro-
In-office bleaching duced better immediate bleaching effects than a non-light system when lower concentra-
Light-activation tions of hydrogen peroxide (15–20% HP) were used (mean difference [MD], 1.78; 95%
Tooth colour confidence interval [CI]: [2.30, 1.26]; P < 0.00001). When high concentrations of HP (25–
Tooth sensitivity 35%) were employed, there was no difference in the immediate bleaching effect (MD, 0.39;
Systematic review 95% CI: [1.15, 0.37]; P = 0.32) or short-term bleaching effect (MD, 0.25; 95% CI: [0.47, 0.96];
Meta-analysis P = 0.50) between the light-activated system and the non-light system. However, the light-
activated system produced a higher percentage of tooth sensitivity (odds ratio [OR], 3.53; 95%
CI: [1.37, 9.10]; P = 0.009) than the non-light system during in-office bleaching.
Conclusions: Light increases the risk of tooth sensitivity during in-office bleaching, and light
may not improve the bleaching effect when high concentrations of HP (25–35%) are employed.
Therefore, dentists should use the light-activated system with great caution or avoid its use
altogether. Further rigorous studies are, however, needed to explore the advantages of this
light-activated system when lower concentrations of HP (15–20%) are used.
# 2012 Elsevier Ltd. All rights reserved.
* Corresponding author at: Department of Operative Dentistry, West China College of Stomatology, Sichuan University, No. 14 Ren Min
South Road, Chengdu 610041, China. Tel.: +86 28 85501439; fax: +86 28 85582167.
E-mail address: jiyao_li@yahoo.com.cn (J.-Y. Li).
0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.04.010
journal of dentistry 40 (2012) 644–653 645
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648 journal of dentistry 40 (2012) 644–653
missing data. Four responded, and one author provided dichotomous data with a 95% confidence interval (CI). The
numerical data that had only been shown graphically in the random effects models were employed for each pooled
original text.19 analysis.
Quality assessments of the included trials were evaluated Heterogeneity was assessed using the Cochran Q test and I2
using the Cochrane risk of bias criteria.21 The assessment statistics, with significance set at P < 0.1. If heterogeneity was
criteria contained six items: sequence generation, allocation significant, a sensitivity analysis was performed to explore the
concealment, blinding of the outcome assessors, incomplete influence of the low quality studies.
outcome data, selective outcome reporting, and other possible All analyses were conducted using RevMan (Review
sources of bias. Manager) version 5.0 software (Cochrane Collaboration,
During data extraction and quality assessment, any Copenhagen, The Netherlands).
disagreements between the reviewers were resolved through
discussion, and if needed, by consulting a third reviewer.
3. Results
2.5. Statistical analysis
3.1. Study characteristics
To summarise bleaching efficacy and tooth sensitivity for each
outcome, we calculated the mean difference (MD) for the The searches yielded 301 citations, including 70 duplicates.
continuous data and risk estimates (odds ratio: OR) for the Among the 231 remaining publications, 11 studies (nine RCTs
and two controlled clinical trials) qualified for this meta- visual measurements of colour change. Two studies showed a
analysis (Fig. 1).4,9,15,17–19,22–26 Among these studies, all 11 more favourable effect of the light-activated system,15,17
studies compared bleaching efficacy, 4,9,15,17–19,22–26 and seven whereas the others did not.4,19,22,23,26 The pooled meta-analysis
studies compared tooth sensitivity.4,9,15,17,22,24,25 of all seven studies showed significant heterogeneity (x2 = 81.45,
Quality assessments showed that five out of the nine RCTs P < 0.00001, I2 = 93%). Sensitivity analysis detected two trials
had low risk of bias,4,15,17,19,24 whereas the remaining four using lower concentrations of HP (15–20% HP)15,17 that were
RCTs had a moderate quality risk of bias.9,18,22,23 Six RCTs mainly responsible for the heterogeneity. Hence, subgroup
adequately described the method of randomisation.4,15,17–19,24 analysis was conducted according to different bleaching
Three of the studies used flipping a coin,4,18,24 and the other concentrations of HP (low concentration: 15–20% and high
three used a random table or random keys.15,17,19 The concentration: 25–35%), thereby avoiding heterogeneity.
allocation concealment was adequate in three RCTs.15,17,22 A subgroup analysis of three studies using high concentra-
All RCTs except for one adopted assessor blinding.4,9,15,18,19,22– tions of HP showed no significant difference between the light-
26
The reporting of dropouts was considered adequate in seven activated system and the non-light system (MD, 0.39; 95% CI:
RCTs.4,9,15,17,19,24,25 Two controlled clinical trials had a high [1.15, 0.37]; Z = 1.00; P = 0.32).4,19,22 In addition, sensitivity
risk of bias.23,26 The main characteristics and methodological analysis also detected two controlled clinical trials with a high
quality of the included trials are summarised in Table 1. risk of bias.23,26 Because these two trials did not influence the
overall effect of the pooled data, they were not included in the
3.2. Bleaching efficacy final meta-analysis. In the two studies that used lower
concentrations of HP (15–20% HP),15,17 the subgroup analysis
3.2.1. Immediate effect (within one day) favoured the use of a light-activated system to produce better
As shown in Fig. 2, seven studies reported the immediate bleaching efficacy (MD, 1.78; 95% CI: [2.30, 1.26]; Z = 6.72;
bleaching efficacy.4,15,17,19,22,23,26 All of the studies adopted P < 0.00001) (Fig. 2 and Table 2).
MD [95% CI] P I2 Py
Bleaching efficacy
Immediate effect High concentration HP 0.39 [1.15, 0.37] 0.32 36% 0.21
Low concentration HP 1.78 [2.30, 1.26] <0.00001 44% 0.18
Short-term effect High concentration HPa 0.25 [0.47, 0.96] 0.50 18% 0.30
High concentration HPb 0.87 [0.23, 1.98] 0.12 0% 0.40
Tooth sensitivity
Incidence of tooth sensitivity 3.53c [1.37, 9.10] 0.009 12% 0.33
Intensity of tooth sensitivity 0.57 [0.21, 0.92] 0.002 16% 0.30
a
Visual measurements of tooth colour.
b
Instrumental measurements of tooth colour.
c
OR.
y
P value for heterogeneity.
650 journal of dentistry 40 (2012) 644–653
Fig. 3 – Short-term bleaching efficacy in light-activated treatment versus non-light treatment, as measured using the visual
method.
3.2.2. Short-term effect (1 week–4 weeks) after 24 weeks of follow-up, when a low concentration HP was
Four studies assessed short-term bleaching effects using used (15%). Bernardon and colleagues,18 however, revealed no
visual measurements.17,18,22,24 Ziemba et al.17 reported signifi- significant differences between the two groups 14 weeks post-
cantly greater shade changes with the light-activated system bleaching in cases where a high concentration of HP (35%) was
than with the non-light system. Heterogeneity was observed utilised. Because of significant heterogeneity and a sample
between different trials. A sensitivity analysis determined that size that was too small in these two studies, meta-analysis
the study by Ziemba et al.17 used lower concentration of HP was not conducted.
(20% HP) than all the other trials.18,22,24 Further subgroup
analysis showed no significant differences between the light- 3.3. Tooth sensitivity
activated system and the non-light system using high
concentrations of HP (MD, 0.25; 95% CI: [0.47, 0.96]; 3.3.1. Likelihood of tooth sensitivity
Z = 0.68; P = 0.50) (Fig. 3 and Table 2). Four studies compared tooth sensitivity using dichotomous
Three studies reported on instrumental measurements of data.4,9,15,25 Heterogeneity was not observed between the
tooth colour in both light-activated and non-light systems.18,23,24 studies. Meta-analysis demonstrated a significantly higher
All such studies employed high concentrations of HP. One likelihood of tooth sensitivity with the light-activated system
controlled clinical trial was excluded because of its high risk of than with the non-light system (OR, 3.53; 95% CI: [1.37, 9.10];
bias.23 No significant heterogeneity was noted in the pooled Z = 2.61; P = 0.009) (Fig. 5 and Table 2).
analysis. Meta-analysis revealed no significant differences
between the light-activated and the non-light system (MD, 3.3.2. Intensity of tooth sensitivity
0.87; 95% CI: [0.23, 1.98]; Z = 1.55; P = 0.12) (Fig. 4 and Table 2). Three studies compared tooth sensitivity using continuous
data.17,22,24 Heterogeneity between the studies was not
3.2.3. Median-term effect (12 weeks–24 weeks) significant. A subsequent meta-analysis favoured the use of
Two studies could be included in this group.15,18 Tavares and non-light systems because they were associated with less
colleagues15 reported that the light-activated system had tooth sensitivity (MD, 0.57; 95% CI: [0.21, 0.92]; Z = 3.12;
significantly better results than the non-light system, even P = 0.002) (Fig. 6 and Table 2).
Fig. 4 – Short-term bleaching efficacy in light-activated treatment versus non-light treatment, as measured using the
instrumental method.
journal of dentistry 40 (2012) 644–653 651
Fig. 5 – Incidence of tooth sensitivity for light-activated treatment versus non-light treatment.
Fig. 6 – Intensity of tooth sensitivity for light-activated treatment versus non-light treatment.
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