Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62: 276–282

doi: 10.1111/adj.12494

Influence of tooth bleaching on dental enamel

microhardness: a systematic review and meta-analysis
J Zanolla,* ABC Marques,* DC da Costa,* AS de Souza,† M Coutinho*
*Faculty of Dentistry, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil.
†Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil.

ABSTRACT
Several studies have investigated the effect of bleaching on dental tissues. The evaluation of the effect of home bleaching
with 10% carbamide peroxide is important for assessing alterations in enamel microhardness that may affect dental
health in terms of resistance to masticatory forces. This meta-analysis was performed in order to determine scientific evi-
dence regarding the effects of home vital bleaching with 10% carbamide peroxide gel on the microhardness of human
dental enamel. A systematic electronic literature search was conducted in the PubMed and Web of Science databases
using search terms. Two independent researchers evaluated the information and methodological quality of the studies.
Inclusion and exclusion criteria were established for article selection; further, only studies published in English were
selected. Thirteen studies that met all of the inclusion and exclusion criteria were selected and underwent statistical anal-
ysis. The results of this meta-analysis showed no significant changes in enamel microhardness when using the 10% car-
bamide peroxide bleaching gel over periods of 7, 14 and 21 days.
Keywords: Bleaching enamel microhardness, bleaching home, carbamide peroxide, enamel microhardness, tooth bleaching.
Abbreviations and acronyms: CI = confidence interval; PRISMA = Preferred Reporting Items for Systematic Reviews and
Meta-Analyses.
(Accepted for publication 8 December 2016.)

The dental bleaching process consists of application

INTRODUCTION
An increasing number of people have begun to seek a
white-toothed smile that gives them a healthier and
more youthful appearance;1 this may increase the like-
lihood of them being placed in an important social
role.2 Home bleaching is a widely used technique
when one seeks colour restoration and aesthetic
improvement, and the interest in this treatment has
increased in recent times.3
The first dental whitening technique was described
by Chapple in 1877,4 but it was not until 1989 that
Haywood and Haymann introduced the at-home vital
bleaching technique.5 The interest in bleaching
increased thereafter,6 owing to its speed and safety.
The free radicals produced by the decomposition of
hydrogen peroxide – the main component of bleach-
ing gels – oxidize the colour-conferring molecules and
promote the bleaching effect. Carbamide peroxide gel
at a concentration of 10% is frequently used in at-
home bleaching procedures for 4–8-h periods per day
over 2 weeks or more.7,8 Its efficacy and safety are
well documented.9,10
276
of the bleaching gel over the dental surface for a long
period of time, which may cause some detrimental
effects on its structure,8 such as: (i) sensitivity due to
the increased enamel porosity (which allows the diffu-
sion of the bleaching gel into the dentin through the
dentinal tubules and further into the dental pulp;5,7,11
(ii) gingivitis;5,12,13 (iii) throat and gastric irrita-
tion;5,13 and (iv) changes in enamel microhardness
and increase in its surface roughness.14
Although at-home bleaching does not produce
macroscopic effects, structural changes and superficial
roughness occur at a microscopic level, leading to pla-
que accumulation and, subsequently, tooth decay and
periodontal disease.15 Carbamide peroxide at a con-
centration of 10% is less toxic to pulp cells when
compared with carbamide peroxide at 16%;11 the lat-
ter also causes major alterations in the enamel surface,
such as loss of mineral structure and increased rough-
ness.16
There is some concern regarding bleaching and the
integrity of the dental structure, as preserving enamel
microhardness is essential to maintain dental health
© 2016 Australian Dental Association

and the ability to resist masticatory, mechanical and
chemical forces. Another concern is the potential
reduction of the adhesive strength capacity in the
presence of bleaching-generated oxygen.17
The use of carbamide peroxide is controversial.
Some studies have shown that there are no significant
changes in enamel surface post-bleaching.6,18–26 How-
ever, others have reported structural changes that
occur with carbamide peroxide at 10%.7,27–34 With
respect to dental bleaching, it is important to mini-
mize risks to ensure that the integrity and longevity of
the dental structure are maintained.3
Because there are conflicting opinions on the
issue of enamel alterations induced by at-home
vital bleaching, a meta-analysis was conducted
using published studies to determine the effects of
home vital bleaching on the microhardness of
human dental enamel. Meta-analysis is a method
that allows the combination of results and statisti-
cal analysis from previous studies to generate a
summary of the findings in order to develop a
derivative new theme or conclusion from already
published data.35
Thus, the aim of the present meta-analysis was to
verify the effect of the bleaching gel agent carbamide
peroxide at a concentration of 10%, on the micro-
hardness of human enamel, when applied for 6–8 h
per day over a period of 7, 14 and 21 days.
MATERIALS AND METHODS
Search method and selection of articles
This systematic literature review was based on the
guidelines from Cochrane Handbook for Systematic
Reviews of Interventions.36 An electronic literature
search of the PubMed and Web of Science databases
was performed between March and July 2016. The
evaluation of information and methodological quality
of the studies was performed independently by two
researchers. The search terms used were: ‘enamel
microhardness’, ‘tooth bleaching’ and ‘carbamide per-
oxide’. The terms were searched in titles, as keywords
and in article abstracts. The search was limited to
articles that were published in English. Full reading of
the papers, the application of the relevance criteria
and the exclusion of duplicates were performed by
two investigators. The remaining articles were selected
on the basis of inclusion criteria, and by reading their
titles and abstracts.
Inclusion criteria were: in vitro and in situ studies,
studies involving human teeth, at-home bleaching
with 10% carbamide peroxide, and Vickers and
Knoop microhardness tests.
Exclusion criteria were: studies involving bovine
teeth, restored teeth, dental office bleaching,
© 2016 Australian Dental Association
10% carbamide peroxide and enamel microhardness
carbamide peroxide concentrations other than 10%,
and nano-hardness test.
After application of the relevance tests, the possibil-
ity of data extraction was verified. The publications
that did not report exact values of microhardness
were excluded. After this analysis, the studies that
met all criteria were included in the meta-analysis
(Table 1).
Data analysis
As recommended by the Cochrane Collaboration,36
the analysis was conducted using the Review Manager
Software (RevMan) version 5.2 (The Cochrane Col-
laboration, Copenhagen, Denmark).37 The data
extracted from the selected studies were limited to the
10% carbamide peroxide-bleached enamel microhard-
ness values in Knoop hardness number and Vickers
hardness number.
For statistical analysis, we employed the random-
effects model with a 95% confidence interval (CI) and
meta-analytical method of inverse variance. This vari-
ability model is directly related to the sample size; the
larger the sample size, the lower the variability and,
therefore, the greater the weight of a given study in
the meta-analysis measure estimate.
RESULTS
Article search results
The flowchart for article selection is shown in Fig. 1,
according to the recommendations for four-phase
flowchart based on the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA).
A total of 5669 publications were found in the two
databases. After reading the titles and applying the
relevance test, 4360 articles remained. The titles and
abstracts were read, yielding 1309 relevant studies,
which were read in full and had the relevance test
applied (Figs. 2, 3 and 4); duplicate entries (N = 124)
were also excluded. Thirty-eight articles remained,
which were analysed in terms of the possibility of
data extraction. However, only 13 studies met all the
inclusion criteria.
RESULTS OF INTERVENTIONS
The results obtained in the meta-analysis for each
bleaching period are represented in the tables and
accompanying forest plots. The weight of each study
in the statistical analysis takes into account the sample
size and intra-sample variability. There is no statistical
difference in the outcome of each study (i.e. no effect)
when its horizontal line, representing the 95% CI,
touches the zero (vertical) line. There is also no
277
J Zanolla et al.

Table 1. Characteristics of the studies included in the meta-analysis

Study Bleaching agent Type of study No. of specimens Application regimen
6
Ara
ujo et al. 10% carbamide peroxide In situ 30 7 h/day for 21 days
Basting et al.7 10% carbamide peroxide In situ 15 8 h/day for 21 days
Rodr
ıgues et al.23 10% carbamide peroxide + placebo In situ 11 6 h/day for 21 days
da Costa et al.27 10% carbamide peroxide In vitro 10 8 h/day for 14 days
de Oliveira et al.29 10% carbamide peroxide In vitro 14 6 h/day for 14 days
Leonard et al.19 10% carbamide peroxide In vitro 10 8 h/day for 14 days
Kwon et al.42 10% carbamide peroxide In vitro 20 6 h/day for 14 days
Pinto et al.28 10% carbamide peroxide In vitro 11 6 h/day for 14 days
Rodr
ıgues et al.24 10% carbamide peroxide In vitro 21 8 h/day for 7 and 14 days
Teixeira et al.20 10% carbamide peroxide In vitro 10 6 h/day for 7 and 14 days
Sunil et al.22 10% carbamide peroxide In vitro 5 8 h/day for 7 days
Dey et al.43 10% carbamide peroxide In vitro 25 8 h/day for 7 days
George et al.38 10% carbamide peroxide In vitro 10 8 h/day for 7 days

the result was statistically significant. The study by

Inial search from databases Rodrigues et al.23 showed an increase in enamel
(n = 5,669) Exclusion based on tles and
abstracts, and applicaon of the
microhardness after bleaching. The other studies
relevance test (n = 4,360) showed no statistical difference in enamel microhard-
ness before and after bleaching for 7 days. The study
1,309 potenally relevant
by George et al.38 showed the greatest weight (17%)
studies Duplicates excluded (n = 124) and
in the analysis. The overall mean difference was 17.61
applicaon of inclusion and
exclusion criteria
(95% CI, 7.46 to 42.69), showing no statistical dif-
38 arcles fulfilling the inclusion and
ference in the reduction of enamel microhardness after
exclusion criteria
7 days (P = 0.17).
Verificaon of the ability to
extract data Figure 3 shows the pre- and post-bleaching (6–8 h
13 included studies
per day) results for a period of 14 days. The studies
Excluded studies (n = 25)
by de Oliveira et al.,29 da Costa et al.27 and Pinto
Fig. 1 Flow diagram of the systematic review according to the Preferred et al.28 showed that enamel microhardness decreased
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) after bleaching, and the result was statistically signifi-
proposal. cant. The study by Rodrigues et al.23 showed an
increase in enamel microhardness after bleaching. The
statistical difference when a horizontal vertex of the other studies showed no statistical difference in
diamond, which represent the 95% CI of the overall enamel microhardness before and after bleaching for
mean of difference, touches the zero line. 14 days. The study by Pinto et al.28 showed the great-
Figure 2 shows the pre- and post-bleaching (6–8 h est weight (14.5%) in the analysis. The overall mean
per day) results for a period of 7 days. The studies by difference was 52.68 (95% CI, 33.52 to 138.89),
de Oliveira et al.29 and George et al.38 showed that showing no statistical difference in the reduction of
enamel microhardness decreased after bleaching, and enamel microhardness after 14 days (P = 0.23).

p
p

Fig. 2 Results obtained pre- (control) and post-bleaching (6–8 h per day) for a period of 7 days. Each study is represented by the symbol : the square
represents the mean difference and the horizontal line emanating from it represents the 95% confidence interval (CI). The symbol represents the overall
effect of the mean difference and its horizontal vertices represent the 95% CI. SD = standard deviation.

278 © 2016 Australian Dental Association

 10% carbamide peroxide and enamel microhardness

p
p

Fig. 3 Results obtained pre- (control) and post-bleaching (6–8 h per day) for a period of 14 days. Each study is represented by the symbol : the
square represents the mean difference and the horizontal line emanating from it represents the 95% confidence interval (CI). The symbol represents the
overall effect of the mean difference and its horizontal vertices represent the 95% CI. SD = standard deviation.

Fig. 4 Results obtained pre- (control) and post-bleaching (6–8 h per day) for a period of 21 days. Each study is represented by the symbol : the square
represents the mean difference and the horizontal line emanating from it represents the 95% confidence interval (CI). The symbol represents the overall
effect of the mean difference and its horizontal vertices represent the 95% CI. SD = standard deviation.

Figure 4 shows the pre- and post-bleaching (6–8 h
per day) results for a period of 21 days. The studies
by Basting et al.7 showed that enamel microhardness
increased after bleaching, and the result was statisti-
cally significant. The other studies showed no statisti-
cal difference in enamel microhardness before and
after bleaching for 21 days. The study by Araujo
et al.6 showed the greatest weight (34.7%) in the
analysis. The overall mean difference was 10.30
(95% CI, 66.63 to 46.02), showing no statistical
difference in the reduction of enamel microhardness
after 21 days (P = 0.72).
The results obtained in the meta-analysis did not
show any reduction in dental enamel microhardness
after at-home bleaching with 10% carbamide perox-
ide when applied for 6–8 h per day over a period of
7, 14 and 21 days.
DISCUSSION
Concern over the safety of bleaching in vital teeth has
been expressed. Hence, at-home bleaching has been
the focus of several reports regarding possible superfi-
cial enamel alterations.
The microhardness test can be used to evaluate the
mechanical properties of enamel after dental bleach-
ing.8 Some studies showed no significant change in
microhardness after at-home vital bleaching.6,18–26
However, some studies showed less favourable
results.7,27–34 Thus, it is not yet clear whether dental
enamel microhardness decreases after application of
10% carbamide peroxide bleaching gel.
For the elaboration of this meta-analysis, the ran-
dom-effects model was used in order to balance the
weight of each study, without devaluing those studies
with smaller sample sizes. According to Borenstein
et al.,39 this is the most suitable option when method-
ologies differ among studies that were performed
without any interconnection.
There are few in vivo studies evaluating enamel
microhardness, because the dental microhardness
analysis technique is unfeasible, owing to requirement
of preparation of specimens on extracted teeth.
In vitro studies were included in the present study,
because the number of in situ research studies for
periods of 7 and 14 days after bleaching was not suf-
ficient for conducting a meta-analysis. The selected
in vitro studies used artificial saliva, which, though
unable to reproduce all the characteristics of the buc-
cal environment, approximates real conditions. Only
three in situ studies with 21 days of bleaching time
were found.
Throughout the development of this meta-analysis,
we found that several methodologies were employed
by various studies. Variations in bleaching time and
period, parameters used in microhardness testing, the

© 2016 Australian Dental Association 279

J Zanolla et al.
commercial brand of the bleaching gel used, and
forms of specimen storage limited the number of arti-
cles used for the meta-analysis.
The studies used healthy extracted human teeth,
without any fracture. The teeth were washed and dis-
infected. The crown was separated from the root, and
only the coronal portion was used. The crown was
then fragmented into small blocks, and their surfaces
were properly planed and polished.
The importance of a polished sample surface for a
microhardness test is to allow observation of the
indenter mark. There are two types of hardness based
on the indenter in use, namely, Vickers and Knoop.
The difference among them lies in the indenter shape.
The Vickers microhardness test leaves a square-shaped
mark, because the indenting diamond has the shape of
a square-based pyramid. The Knoop microhardness
indenter is shaped like a pyramidal diamond, leaving
the mark of a lozenge.40 Microhardness tests were
applied before and after bleaching, according to the
proposed bleaching time of each study (7, 14 and
21 days).
In 1996, McCracken and Haywood41 compared the
10% carbamide peroxide bleaching procedure with
the intake of a cola-based beverage for 2.5 min and
with a prophylactic treatment. The authors found that
the amount of calcium lost in the three procedures
was the same (5–50 lm of surface enamel),41 which is
consistent with the present study. According to the
results of Sunil et al.,22 the 10% carbamide peroxide-
bleached group experienced a minor (25 lm) reduc-
tion in enamel microhardness.
Demineralization can also be affected by the degree
of acidity of the gel. The lower the pH of the gel, the
greater the solubility of calcium and phosphate pre-
sent in the enamel will be. Bleaching gels with a criti-
cal pH (between 5.2 and 5.8) can alter the enamel
surface and cause demineralization.7,31,32 However, as
the bleaching gel dissociates in the mouth, its pH
increases.7 The remineralizing effect of saliva and the
degradation of 10% carbamide peroxide in ammonia
may increase the pH value and render the demineral-
ization potential of the bleaching gel ineffective.22
Different commercial brand products have varying
formulations and pH values, even if the active princi-
ple is the same.6 However, the pH is not a crucial fac-
tor in microhardness alterations.32 The enamel surface
may be subjected to small damages that increase its
roughness, despite having no significant decrease in its
microhardness.23,28,31–33 The possible factors that
may account for this outcome include the following:
low pH,7,30,31 presence of acidic carbopol sub-
stances,21 and a long time of contact between the den-
tal surface and the bleaching gel,7 especially at night
when the amount of saliva decreases, making it diffi-
cult to increase the pH.
280
Scanning electron microscopy shows the surface of
non-bleached enamel and surface roughness after
using 10% carbamide peroxide bleaching gel.28 The
use of 10% carbamide peroxide leads to increased
surface roughness, with the presence of pits, dimples
and erosions.25,28,31,32 The pores increase, with the
appearance of surface erosion defects immediately
after bleaching, which may disappear after 3 months
owing to the remineralizing effect of saliva.34
Ara
ujo et al.6 emphasized the important role of sal-
iva in the remineralization process of bleached enamel
application of the bleaching gel on teeth undergoing a
bleaching programme.6 The loss of mineral ions can
be controlled naturally by saliva and by fluorinated
solutions.21,30 Murchison et al.,26 while using artificial
saliva as storage medium, did not observe statistical
differences pre- and post-bleaching.26
The use of 10% carbamide peroxide has minimal
effects on the enamel surface morphology,21 and these
effects do not worsen with time.25 The effect of 10%
carbamide peroxide is equivalent to that of 3.5%
hydrogen peroxide; however, the former is more
stable and releases oxygen more slowly.20
As shown in Figs. 2, 3 and 4, the statistical analysis
showed no significant difference between pre-bleach-
ing (control) and post-bleaching with 10% carbamide
peroxide in dental enamel microhardness over 7, 14
and 21 days. These results are in agreement with find-
ings from several previously published studies.6,18–
26,38,42,43
In the present work, we performed a meta-analysis
of studies that applied 10% carbamide peroxide
bleaching gel for 6–8 h per day (time of exposure)
and measured the microhardness value for periods of
7, 14 and 21 days post-bleaching. Thus, the results do
not extend either to clinical applications for longer
periods, or to frequency of gel usage. Further studies
are required in this regard.
CONCLUSION
Based on the results obtained from this meta-analysis,
we conclude that enamel microhardness does not
decrease after application of 10% carbamide peroxide
bleaching gel for 6–8 h per day over a period of 7, 14
or 21 days.
REFERENCES
1. Sasaki RT, Arcanjo AJ, Fl
orio FM, Basting RT. Micromor-
phology and microhardness of enamel after treatment with
home-use bleaching agents containing 10% carbamide perox-
ide and 7.5% hydrogen peroxide. J Appl Oral Sci
2009;17:611–616.
2. Fatima N, Abidi SYA, Meo AA. In vitro comparative study of
two different bleaching agents on micro-hardness dental
enamel. J Coll Physicians Surg Pak 2016;26:83–86.
© 2016 Australian Dental Association

3. Moosavi H, Darvishzadeh F. The influence of post bleaching in
stain absorption and microhardness. Open Dent J 2016;10:69–
78.
4. Chapple JA. Restoring discolored teeth to normal. Dent Cosmos
1877;19:499.
5. Haywood VB, Heymann HO. Nightguard vital bleaching.
Quintessence Int 1989;20:173–176.
6. Araujo EM, Baratieri LN, Vieira LC, Ritter AV. In situ effect
of 10% carbamide peroxide on microhardness of human
enamel: function of time. J Esthet Restor Dent 2003;15:166–
173.
7. Basting RT, Rodrigues JA, Serra MC. The effect of 10% car-
bamide bleaching material on microhardness of sound and dem-
ineralized enamel and dentin in situ. Oper Dent 2001;26:531–
539.
8. Ghanbarzadeh M, Ahrari F, Akbari M, Hamzei H. Microhard-
ness of demineralized enamel following home bleaching and
laser-assisted in office bleaching. J Clin Exp Dent 2015;7:405–
409.
9. Rezende M, Ferri L, Kossatz S, Loguercio AD, Reis A. Com-
bined bleaching technique using low and high hydrogen perox-
ide in-office bleaching gel. Oper Dent 2016;41:388–396.
10. Wang Y, Gao J, Jiang T, Liang S, Zhou Y, Matis BA. Evalu-
ation of the efficacy of potassium nitrate and sodium fluoride
as desensitizing agents during tooth bleaching treatment. A
systematic review and meta-analysis. J Dent 2015;43:
913–923.
11. Soares DG, Ribeiro AP, Lima AF, Sacono NT, Hebling J, de
Souza Costa CA. Effect of fluoride-treated enamel on indirect
cytotoxicity of a 16% carbamide peroxide bleaching gel to pulp
cells. Braz Dent J 2013;24:121–127.
12. Dahl JE, Pallesen U. Tooth bleaching – a critical review of
the biological aspects. Crit Rev Oral Biol Med 2003;14:292–
304.
13. Leonard RH, Haywood VB, Phillips C. Risk factors for
developing tooth sensivity and gingival irritation associated
with nightguard vital bleaching. Quintessence Int 1997;28:
527–534.
14. Cvilk B, Lussi A, Moritz A, Flury S. Enamel surface changes
after exposure to bleaching gels containing carbamide peroxide
or hydrogen peroxide. Oper Dent 2016;41:39–47.
15. Fatima N. In-vitro comparative study of in-office and home
bleaching agents on surface micro-morphology of enamel. J
Coll Physicians Surg Pak 2016;26:9–12.
16. Soares DG, Ribeiro APD, Sacono NT, Logu
ercio AD, Hebling
J, Costa CAS. Mineral loss and morphological changes in den-
tal enamel induced by a 16% carbamide peroxide bleaching
gel. Braz Dent J 2013;24:517–521.
17. Oskoee PA, Navimipour EJ, Oskoee SS, Moosavi N. Effect of
10% sodium ascorbate on bleached bovine enamel surface:
morphology and microhardness. Open Dent J 2010;4:207–210.
18. Lopes GC, Bonissoni L, Baratieri LN, Vieira LC, Monteiro S.
Effect of bleaching agents on the hardness and morphology of
enamel. J Esthet Restor Dent 2002;14:24–30.
19. Leonard RH, Teixeira EC, Garland GE, Ritter AV. Effect on
enamel microhardness of two consumer-available bleaching
solutions when compared with a dentist-prescribed, home-
applied bleaching solution and a control. J Esthet Restor Dent
2005;17:343–350.
20. Teixeira EC, Ritter AV, Thompson JY, Leonard Rh JR, Swift
EJ. Effect of tray-based and trayless tooth whitening systems on
microhardness of enamel surface and subsurface. Am J Dent
2004;17:433–436.
21. Akal N, Over H, Olmez A, Bodur H. Effects of carbamide per-
oxide containing bleaching agents on the morphology and sub-
surface hardness of enamel. J Clin Pediatr Dent 2001;25:293–
296.
© 2016 Australian Dental Association
10% carbamide peroxide and enamel microhardness
22. Sunil CR, Sujana V, Choudary TM, Nagesh B. In vitro action
of various carbamide peroxide gel bleaching agents on the
micro hardness of human enamel. Contemp Clin Dent
2012;3:193–196.
23. Rodrigues JA, Marchi GM, Ambrosano GM, Heymann HO,
Pimenta LA. Microhardness evaluation of in situ vital bleaching
on human dental enamel using a novel study design. Dent
Mater 2005;21:1059–1067.
24. Rodr
ıgues JA, Basting RT, Serra MC, Rodr
ıgues J

unior AL.
Effects of 10% carbamide peroxide bleaching materials on
enamel microhardness. Am J Dent 2001;14:67–71.
25. Leonard RH, Eagle JC, Garland GE, Matthews KP, Rudd
AL, Phillips C. Nigthguard vital bleaching and its effect on
enamel surface morphology. J Esthet Restor Dent
2001;13:132–139.
26. Murchison DF, Charlton DG, Moore BK. Carbamide peroxide
bleaching efficacy on enamel surface hardness and bonding.
Oper Dent 1992;17:181–185.
27. da Costa JB, Mazur RF. Effects of new formulas of bleaching
gel and fluoride application on enamel microhardness: an
in vitro study. Oper Dent 2007;32:589–594.
28. Pinto CF, Oliveira R, Cavalli V, Giannini M. Peroxide bleach-
ing agent effects on enamel surface microhardness, roughness
and morphology. Braz Oral Res 2004;18:306–311.
29. de Oliveira R, Paes Leme AF, Giannini M. Effect of carbamide
peroxide bleaching gel containing calcium or fluoride on
human enamel surface microhardness. Braz Dent J 2005;16:
103–106.
30. Cavalli V, Giannini M, Carvalho RM. Effect of carbamide per-
oxide bleaching agents on tensile strength of human enamel.
Dent Mater 2004;8:733–739.
31. Bitter NC. Scanning electron microscopy study on the effect of
bleaching agents on enamel: a preliminary study. J Prosthet
Dent 1992;67:852–855.
32. Bitter NC, Sanders JL. The effect of four bleaching agents on
the surface: a scanning electron microscopy study. Quintessence
Int 1993;24:817–824.
33. T€urkun M, Sevgican F, Pehlivan Y, Aktener BO. Effects of
10% carbamide peroxide on the enamel surface morphology: a
scanning electron microscopy study. J Esthet Restor Dent
2002;14:238–244.
34. Leandro GA, Attia ML, Cavalli V, do Rego MA, Liporoni PC.
Effects of 10% carbamide peroxide treatment and sodium fluo-
ride therapies on human enamel surface microhardness. Gen
Dent 2008;56:274–277.
~ es e sinergia com
35. Luiz AJB. Meta-an
alise: definicß~ao, aplicacßo
dados espaciais. CC&T 2002;19:407–428.
36. Higgins JPT, Green S (eds). Cochrane Handbook for Systematic
Reviews of Interventions. Version 5.1.0. The Cochrane Collab-
oration, 2011. Available at: http://handbook.cochrane.org.
Accessed March, 2016.
37. Review Manager (RevMan) [Computer program]. Version 5.2.
Copenhagen: The Nordic Cochrane Centre, The Cochrane Col-
laboration, 2014. Accessed June, 2016.
38. George L, Baby A, Dhanapal TP, Charlie KM, Joseph A,
Varghese AA. Evaluation and comparison of the microhardness
of enamel after bleaching with floride free and floride contain-
ing carbamide peroxide bleaching agents and post bleaching
anticay application: an in vitro study. Contemp Clin Dent
2015;6:163–166.
39. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. From
Matter, in Introduction to Meta-Analysis. Chichester, UK: John
Wiley & Sons Ltd. Published Online: 11 MAR 2009. Doi: 10.
1002/9780470743386.refs.
40. Sostena MMDS. Influence of humidity, temperature and time of
irradiation on physical properties of composite resins used in
orthodontics. PhD Thesis. Bauru: UNESP, 2009.
281
J Zanolla et al.

41. Mc Cracken MS, Haywood VB. Demineralization effects Address for correspondence:
of 10 percent carbamide peroxide. J Dent 1996;24:
395–398.
Professor Margareth Coutinho
Faculty of Dentistry
42. Kwon SR, Kurti SR, Oyoyo U, Li Y. Effect of various tooth
whitening modalities on microhardness, surface roughness and Federal University of Mato Grosso do Sul
surface morphology of the enamel. Odontology 2015;103:274– University City
279. CEP 79070-900
43. Dey S, Pandey V, Kumar A, Awasthi N, Sahu A, Pujari SC. In Campo Grande, MS
vitro comparison of impact of different bleaching agents on the
microhardness of enamel. J Contemp Dent Pract 2016;17:258– Brazil
262. Email: margareth.coutinho@ufms.br

282 © 2016 Australian Dental Association