Received: 19 September 2017 Revised: 1 October 2018 Accepted: 2 October 2018

DOI: 10.1111/jerd.12440

RESEARCH ARTICLE

A 3 months clinical evaluation comparing two professional

bleaching systems of 25% and 40% hydrogen peroxide
and extended treatment outcome using a power versus a
manual toothbrush
Sean S. Lee1 | So Ran Kwon1 | Marilyn Ward2 | Wendy Jenkins2 | Sonia Souza3 |
Yiming Li1

1
Center for Dental Research, Loma Linda
University School of Dentistry, Loma Linda, Abstract
California Objectives: To assess two professional tooth bleaching products: Philips Zoom WhiteSpeed
2
Philips Oral Healthcare, Bothell, Western (PZW) and Ultradent Opalescence Boost PF (UOB); and to assess bleaching maintenance after
Australia
use of Philips Sonicare power toothbrush (SDC) or manual toothbrush (MTB).
3
Portola pharmaceuticals, South San Francisco,
Methods: There was a randomized, parallel clinical trial. Eligible subjects were 18-75 years, with
California
VITA Classical shade (VCS) of A3 on anterior teeth. Subjects were randomized to bleaching with
Correspondence
Sean S. Lee, Center for Dental Research, Loma PZW or UOB. Tooth color and shade were assessed using VITA EasyShade (VES), VCS, and
Linda University School of Dentistry, 11175 VITA Bleachedguide (VBG). Subjects returned on Days 7 and 30. On Day 30, participants were
Campus Street, Loma Linda, CA 92350. dispensed either SDC or MTB for home use until Day 90.
Email: seanlee@llu.edu
Results: A total of 135 subjects completed the study. For the primary endpoint, ΔE at Day 7, a signifi-
Funding information
Philips Oral Healthcare, Grant/Award Number:
cantly larger reduction was observed for PZW than UOB (P value = .0059). Significant differences in
2120097 shade were also observed at Day 7 for VCS (P value = 0.0106), and VBG (P value = .0489). On Day
90, the SDC was statistically superior to MTB in maintaining shade per VBG and VCS, but not ΔE.
Conclusions: At Day 7, PZW showed statistically greater change in overall color and shade than UOB.
The SDC maintained tooth shade significantly better than MTB. Both bleaching regimens were safe.
Clinical Significance: The outcomes confirm the bleaching efficacy advantage of a lower H2O2
dose-LED accelerated professional tooth bleaching system, compared to a higher-dose H2O2
approach. The safety assessments via clinical intraoral exam and daily logged use of subjects'
desensitizing agents, and the incidence and severity of reported sensitivity, provide evidence
that both professional products are safe for use. Finally, powered tooth brushing may confer an
advantage to manual tooth brushing in maintaining tooth shade-change results following profes-
sional whitening.

KEYWORDS

hydrogen peroxide, opalesence boost, Philips zoom, power Tooth brushing, tooth bleaching,
tooth whitening

1 | I N T RO D UC T I O N applications also include the addition of light to potentiate the absorp-

tion of H2O2. However, clinical research on the direct comparison of
In-office tooth bleaching applications utilize high concentrations of efficacy of H2O2 administration with and without light has been lim-
hydrogen peroxide (H2O2) gel, typically ranging from 25% to 40%, to ited. The same applies to the safety profile of the two different
elicit a whitening effect in anterior dentition. Some chair-side approaches; there are insufficient data to make any evidence-based

J Esthet Restor Dent. 2018;1–8. wileyonlinelibrary.com/journal/jerd © 2018 Wiley Periodicals, Inc. 1

2 LEE ET AL.
assertions regarding one tooth bleaching method relative to another.
It is unclear whether a lower-dose H2O2 chair-side bleaching applica-
tion puts the patient at a higher risk in the presence of light, or
whether a high concentration H2O2 application trades efficacy for
sensitivity-related sequelae.
To compound the challenge in comparability, conflicting evidence
is reported on the value and influence of H2O2 administration in the
presence of light. 1–4
In addition, changes to tooth surface hardness,
enamel density, and color from remineralizing agents included with
the bleaching gel, such as calcium, fluoride and hydroxyapatite,5–12
further complicate the ability to readily decipher comparisons.13–15
This reinforces the importance of comparative research on the bene-
fits and risks of not only individual active ingredients as options, but
the combinations used, to make an informed decision regarding tooth
bleaching treatment approaches best aligned with a patient's needs.
While tooth bleaching remains the most commonly requested cos-
metic dental treatment, comprising 32% of all treatments requested
according to a 2015 survey by the American Academy of Cosmetic
Dentistry,16 maintaining newly bleached tooth color warrants attention as
well. Patient-driven interest regarding the maintenance of bleaching out-
comes is commonly expressed, especially by those who may experience
color rebound in as little as 2 months.17–20 These individuals may be more
likely to inquire about maintenance using professionally recommended
home-care strategies. Some patients may elect to extend improved tooth
color post-bleaching and return once or twice yearly for touch up mainte-
nance protocol at the dental office, while others who prefer home oral
hygiene-based strategies may opt to use powered toothbrushes. In prior
published research, this category of products has been shown to remove
more stain and plaque than manual tooth brushing alone.21–23
A 2006 Cochrane review encouraged pragmatic long-term studies of
24
tooth bleaching products, and the CONSORT statement defined rigor-
ous design, analysis and reporting of oral health trials.25 The present
study was conducted following these guidelines with consideration of
available literature on chair-side bleaching and powered toothbrushes.
The current study was designed to provide clarity with respect to
the clinical safety and efficacy profile of two commonly used chair-sides,
peroxide-based, tooth bleaching regimes; one regimen that utilizes LED
light acceleration, and one that does not. Our first null hypothesis was
that there would be no difference between the chairside bleaching that
uses light versus the nonlight activated regimen. We were also interested
to explore whether powered tooth brushing helps prolong bleaching out-
comes, irrespective of a given chair-side bleaching regimen, compared to
manual tooth brushing. Our second null hypothesis was that there would
be no difference in maintaining bleached shade between the powered
and manual toothbrush. The resultant studies outcomes could, therefore,
help inform those options that are most suited to assisting patients
achieve the desired tooth bleaching effects, safely.
2 | MATERIALS AND METHODS
2.1 | Study design and objectives
This was a two-phase, randomized, parallel clinical trial that was
approved by an Institutional Review Board. The primary objective of
phase I was to compare the bleaching effect of Philips Zoom White-
Speed (PZW) with 25% Hydrogen Peroxide (H2O2) plus LED versus
Ultradent Opalescence Boost PF (UOB) with 40% H2O2 at 7 days fol-
lowing application as measured by ΔE per VITA EasyShade spectro-
photometer (VES, VITA North America, Yorba Linda, CA). Secondary
objectives of phase I included: comparison of the bleaching effect of
PZW versus UOB immediately and 30 days following application, as
measured by ΔE, comparison of tooth shade change for PZW versus
UOB immediately following treatment, and at 7 and 30 days following
treatment as measured by VITA Classical Shade Guide (VCS, VITA
North America) and VITA Bleachedguide 3-D MASTER (VBG, VITA
North America), and to assess subject-reported sensitivity and safety
events for each product. For study phase II, the primary objective was
to compare the ability of the Sonicare DiamondClean power tooth-
brush (SDC) vs MTB to maintain tooth bleaching outcomes per ΔE,
VCS and VBG at 90 days postbleaching.
2.2 | Subjects
The study included the following entry criteria: age 18-75 years, in
generally good health, nonsmoker, presenting with a tooth shade of
A3 or greater as assessed by VCS on a minimum of four of six maxil-
lary, restoration-free, anterior teeth. Subjects presenting with any of
the following conditions were excluded: severely malposed anterior
teeth, visible supragingival plaque on the facial surface of the anterior
teeth, current use of systemic anti-inflammatory or immunosuppres-
sive therapy, prior history of tetracycline use or the presence of tetra-
cycline staining on teeth, chair-side bleaching within the last 2 years,
current sensitivity on the facial surface of anterior teeth, pregnant or
nursing. The only dietary restriction observed during the study was
for the 2 hours period immediately following chair-side bleaching,
where subjects were prohibited from ingesting dark-staining foods.
2.3 | Study treatment groups
There were two treatment groups in study phase I:
• Philips Zoom WhiteSpeed (PZW) application in the presence of
LED light with intensity at 190 mW/cm2, over a period of
15 minutes, for 3 cycles as per manufacturer's instructions.
• Ultradent Opalesence Boost (UOB) application over a period of
20 minutes, for 2 cycles as per manufacturer's instructions.
Products were applied to the facial surface of the upper maxillary
teeth, from tooth number 6-11, as well as of the mandibular teeth,
from tooth number 22-27. Bleaching was followed by application of a
desensitizing agent, Relief ACP (5% potassium nitrate, amorphous cal-
cium phosphate and fluoride) for 10 minutes or UltraEZ, (potassium
nitrate, fluoride) for 5 minutes, PZW and UOB, respectively. Each sub-
ject received home desensitizing agent to be applied, as dictated by
symptoms of sensitivity.
For phase II, the study products included the following: Philips
Sonicare DiamondClean power toothbrush with standard size Dia-
mondClean brush head (SDC), or an American Dental Association
(ADA) reference manual toothbrush (MTB).
LEE ET AL.
2.4 | Description of study visits and procedures
The study was comprised of five clinic visits over a period of up to
97 days. The study visit schedule and procedures are depicted in
Figure 1.
At Visit 1, subjects provided Informed Consent and underwent
eligibility screening. All subjects had a custom jig fabricated at one of
the central incisors to enable consistent VES measurements.
At Visit 2, designated study personnel performed the baseline
tooth color assessments (VES, VCS, VBG). Subjects underwent a lim-
ited rubber-cup polish with fine pumice and water, followed by tooth
bleaching, PZW or UOB. All subjects then underwent repeat efficacy
evaluations and completed a Sensitivity Questionnaire. Subjects were
provided a log for home daily recording of events of sensitivity and/or
the use of desensitizing agents. All subjects received an ADA refer-
ence manual toothbrush and Crest Cool Mint Gel dentifrice (Procter &
Gamble, Cincinnati, OH) for twice-daily home use. Subjects were
instructed to refrain from use of any other oral hygiene or oral cos-
metic procedures.
Study Visit 3 was completed in clinic 7 days following Visit 2 and
included safety and efficacy evaluations.
Study Visit 4 was completed 30 days following Visit 2. Subject
safety and efficacy examinations were performed. For phase II,
FIGURE 1 Study flow diagram
3
subjects were randomized to one of the following home use regimes:
powered tooth brushing with SDC or an ADA reference MTB.
Study Visit 5 was completed 90 days following Visit 2 and repre-
sents 60 days use of the assigned home-use toothbrush. Subject
safety and efficacy examinations were performed.
2.5 | Randomization, blinding, and data capture
For phase I, randomization was stratified by gender. For phase II, ran-
domization was balanced by phase I bleaching treatment (PZW or
UOB) and gender. Examiners who performed clinical efficacy assess-
ments were blinded to the groups for both phases I and II, while sub-
jects were blinded only during phase I. Study data were collected on
an Electronic Data Capture (EDC) System and monitored to ensure
accuracy of the data set.
2.6 | Efficacy measurements
2.6.1 | Tooth Color & Tooth Shade
Tooth color was assessed using the VITA EasyShade device (VES),
which measures the color coordinates for L*, a*, and b*. Tooth shade
was assessed using the VITA Classical Shade Guide (VCS), and the
VITA Bleachedguide 3D Master (VBG) under color controlled lighting
4 LEE ET AL.

conditions (5500 K). The VCS was arranged according to value from
the highest (B1) to lowest (C4) and numbered accordingly from 1 to
16. The VBG was organized from the highest value (0 M1) to lowest
value (5 M3) and numbered from 1 to 15. Two inter-calibrated Exam-
iners performed the shade evaluations. If the Examiners did not con-
cur in their assessments, a consensus review and agreement was
required.
2.7 | Safety measurements
Safety was assessed by intraoral examination, interview and record of
changes in a subject's medical and dental status relative to Baseline,
and by daily home sensitivity log and clinic visit questionnaire. Any
report of sensitivity was recorded as a side effect.
3 | STATISTICAL METHODS
3.1 | Sample size determination
A prior study 26
reported a difference of 1.3 for ΔE between two
peroxide-based light versus no light regimens. In this study, a sample
size of 60 subjects completing in each group would have 80% power
to detect a difference in mean ΔE of 1.3 at Day 7.
3.2 | Primary efficacy analysis
The primary efficacy measure for this study was the change in tooth
color (ΔE) between Baseline and Day 7 post-bleaching. Color change
(ΔE) was calculated as follows:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ΔE ¼ ðΔLÞ2 + ðΔaÞ2 + ðΔbÞ2 :
Comparisons between treatment groups were performed using
an F Test. If the data were not normally distributed, a Kruskal-Wallis
(KW) test was used.
4 | RE SU LT S
4.1 | Phase I: Baseline characteristics
Among 394 subjects screened, 136 qualified and enrolled in study
phase I, with 67 subjects randomized to PZW and 69 to UOB. The dis-
tributions of age and gender, as well as the tooth color and shade
were comparable between the two groups. All randomized subjects
were reported as compliant with the protocol requirements (abstained
from using whitening products not associated with the study,
refrained from smoking and consuming dark staining foods for 2 hours
postbleaching, etc.).
4.2 | Phase I: Efficacy
The distributions of ΔE by treatment group are presented in Figure 2.
The data were not normally distributed (Kolmogorov-Smirnov,
P < .010). Therefore, a non-parametric KW model was implemented.
The results for ΔE, as well as for ΔL, Δa, and Δb, are presented in
Table 1. For the primary efficacy objective, the median ΔE at Day
7, the outcome for PZW was 6.34, compared to 4.08 for UOB, this
difference was statistically significant (P = .0059).
For immediately postbleaching and at Day 30, similar KW ana-
lyses were performed. The median ΔE for immediately postbleaching
was 5.12 for PZW, and 2.55 for UOB (P < .0001). For Day 30, the
median ΔE was 6.03 for PZW, and 3.44 for UOB (P = .0019).
For Δb*, statistically significant differences (P < .010) were
observed for - PZW compared to UOB at each time point: immedi-
ately post, Day 7 and Day 30.
For ΔL*, statistical significance (P = .0030) was observed
between PZW and UOB at the immediately post time point, only.
The Baseline values and the distributions of change from Baseline
in the VCS and VBG Shade Guide endpoints are presented in Figures 3
and 4. For these endpoints, the residual analysis indicated normal

3.3 | Secondary efficacy endpoint analysis

Secondary analyses were performed for color change (ΔE) immedi-
ately after and 30 days postbleaching. In addition, the same set of
analyses was performed for shade change (VCS, VBG). A supplemen-
tary analysis of all color change variables was performed using a
mixed model with evaluation period and treatment included in the
model. For phase II, treatment groups of interest for the analysis
were PTB and MTB. The analysis model included the phase I treat-
ment and the interaction between phase I treatment and brush type
used in phase II.

3.4 | Safety analysis

Subject reports of sensitivity were analyzed using descriptive statis-
tics. The number and percent of subjects for sensitivity in each group FIGURE 2 Phase I boxplot, VITA EasyShade ΔE postbleaching, day
were presented by treatment group and time point. 7, and day 30
LEE ET AL. 5

TABLE 1 Phase I nonparametric Kruskal-Wallis analysis, VITA EasyShade ΔL*, Δa*, Δb*, and ΔE

Treatment Kruskal-Wallis summary

Visit Statistic PZW (n = 67) a
UOB (n = 68) Shift (SE)b 95% CL P valuec
ΔE
Postbleaching Median 5.12 2.55 2.02 1.16, 2.94 <.0001
(0.456)
Day 7 Median 6.34 4.08 1.48 0.50, 2.68 .0059
(0.556)
Day 30 Median 6.03 3.44 1.78 0.70, 2.92 .0019
(0.568)
ΔL*
Postbleaching Median 3.10 1.60 1.40 0.40, 2.40 .0030
(0.510)
Day 7 Median 1.80 1.95 0.00 −1.10, 1.00 .9912
(0.536)
Day 30 Median 2.05 1.95 0.10 −0.90, 1.00 .8395
(0.485)
Δa*
Postbleaching Median 0.30 −0.35 0.60 0.40, 0.80 <.0001
(0.102)
Day 7 Median −0.50 −0.85 0.30 0.10, 0.60 .0074
(0.128)
Day 30 Median −0.60 −0.60 0.20 −0.10, 0.50 .1575
(0.153)
Δb*
Postbleaching Median −2.80 −0.80 −2.20 −3.10,-1.30 <.0001
(0.459)
Day 7 Median −4.60 −2.90 −1.70 −2.80, −0.70 .0019
(0.536)
Day 30 Median −4.15 −2.30 −1.90 −2.90, −0.90 .0004
(0.510)

Nonparametric Kruskal-Wallis ANNOVA Model: Result = Phase 1 Treatment (Zoom WhiteSpeed or Opalescence Boost) + error.
a
At Day 30, there were 66 subjects in PZW treatment group.
b
Both the SE (SE) and the 95% confidence interval (CI 95%) are based on asymptotic procedure.
c
P value is based on Kruskal-Wallis Test (Ho: No difference between the median for the two treatments).

distribution. Therefore, a parametric analysis of variance was used. 4.3.2 | Side effects (SEs)
These outcomes are provided in Table 2. There were 23 SEs among 17 subjects reported in the PZW group,
In summary, for VCS, statistically significant differences were and 18 SEs among 17 subjects reported in the UOB group. For the
observed between PZW and UOB immediately post-bleaching UOB group, all SEs were associated with tooth sensitivity, except for
(P < .0001), and at Day 7 (P = .0106). A similar trend was observed
for VBG, with statistically significant differences observed at the same
time points (P < .0001 at immediately post; and P = .0489 at Day 7).

4.3 | Phase I: Safety

4.3.1 | Sensitivity questionnaire
In general, the incidence of sensitivity was low for both bleaching sys-
tems. Immediately following bleaching, 98.5% of PZW subjects, and
95.6% of UOB subjects, reported “no sensitivity.” Of those who did
experience sensitivity, the severity was reported as “mild.” At Day
7, 82.1% of PZW and 79.4% of UOB subjects reported “no sensitiv-
ity.” Of those who did experience sensitivity, 16.4% of PZW and
20.6% of UOB reported sensitivity severity as “mild,” and 1.5% of
PZW subjects reported severity as “moderate.” At Day 30, 100% of
PZW and 97.1% of UOB subjects reported “no sensitivity.” Of those
2.9% of UOB subjects who did report sensitivity, severity was indi-
cated as “mild.” FIGURE 3 Phase I boxplot, VITA classical shade guide
6 LEE ET AL.

approximately equal numbers of PZW and UOB subjects were allo-

cated across the SDC and MTB treatment groups. A total of 133 sub-
jects completed the study. The Baseline VES, VCS and VBG values for
study phase II, were the Day 30 outcomes observed in study phase I.

4.5 | Phase II: Efficacy

At Day 90, the median ΔE for SDC was 2.51, and 2.49 for MTB, this
difference was not statistically significant (P = .9690).
The outcomes for phase II Shade Guide assessments are pre-
sented in Table 3. The LS Mean (SE) VCS shade change was −0.77
(0.22) for SDC and was 0.47 (0.22) for MTB (P < .0001). For VBG, the
LS Mean (SE) shade change from Day 30 to Day 90 was −0.29 (0.12)
for SDC compared with 0.15 (0.12) for MTB (P = .0108).

4.6 | Phase II: Safety

FIGURE 4 Phase I boxplot, VITA bleached guide 3D master
one report of gum irritation. For the PZW group, most SEs was associ-
ated with sensitivity. These were consistent with discomfort associ-
ated with the use of retractors during the in-office bleaching
procedure. There was no ongoing SEs or reports of sensitivity upon
conclusion of study phase I. With respect to home use of desensitizing
agents following the bleaching procedure, there were a total of five
reported uses. Two of these were from two subjects in the PZW
group, and three uses were reported from two subjects in the UOB
group. No unexpected adverse effects were observed among subjects
of the both groups.
4.4 | Phase II: Baseline characteristics
Of the 134 subjects who completed study phase I, 134 continued on
study participation to phase II. Of these, 67 were randomized to SDC
and 67 to MTB. Randomization was balanced to ensure that
There was no ongoing SEs attributed to the tooth brushing regimes,
or reports of sensitivity as a result of in-office bleaching, upon conclu-
sion of study phase II.
5 | DI SCU SSION
A number of factors have been associated with tooth bleaching effi-
cacy, including the concentration of H2O2 in a bleaching gel formula-
tion, the contact time of the gel on the tooth surface, the subject's
Baseline tooth color, his/her prior medical and dental history and life-
style habits, and the use of auxiliary accelerators for bleaching treat-
ment, such as light. There has been an assumption that whitening
formulas of higher H2O2 concentrations are more effective in bleach-
ing teeth.27,28 Similarly, it is believed that power tooth brushing is
more effective than manual tooth brushing for removing plaque and
stains, as well as improving gingival index scores,29,30 the same has
been assumed for maintaining tooth shade after the bleaching

TABLE 2 Phase I VITA classical shade guide and VITA bleached guide

Treatment
Visit Statistic PZW (n = 67)a UOB (n = 69) Difference P valueb
VCS
Postbleaching LS mean (SE) −5.86 (0.18) −4.47 (0.18) −1.39 (0.26) <.0001
95% CI −6.21, −5.50 −4.83, −4.11 −1.89, −0.88
Day 7 LS mean (SE) −4.92 (0.20) −4.19(0.20) −0.74 (0.28) .0106
95% CI −5.32, −4.52 −4.58, −3.79 −1.30, −0.17
Day 30 LS mean (SE) −4.45 (0.21) −4.11 (0.21) −0.34 (0.30) .2648
95% CL −4.87, −4.02 −4.53, −3.69 −0.93, 0.26
VBG
Postbleaching LS mean (SE) −3.24 (0.11) −2.05 (0.11) −1.20 (0.15) <.0001
95% CI −3.46, −3.03 −2.26, −1.84 −1.50, −0.90
Day 7 LS mean (SE) −2.41 (0.13) −2.06 (0.12) −0.35 (0.18) .0489
95% CI −2.66, −2.16 −2.30, −1.81 −0.70, −0.00
Day 30 LS mean (SE) −2.25 (0.12) −2.03 (0.12) −0.23 (0.17) .1977
95% CL −2.50, −2.01 −2.27, −1.79 −0.57, 0.12

Parametric ANOVA Model: Result = Phase 1 Treatment (Zoom WhiteSpeed or Opalescence Boost) + error.
a
At Day 30, there were 66 subjects in PZW treatment group.
b
P value is based on an ANOVA model F test (Ho: No difference between treatments). P value is based on t test (Ho: Mean Treatment = 0).
LEE ET AL. 7

TABLE 3 Phase n ANOVA, change from baseline VITA classical shade guide and VITA bleached guide

Treatment
Visit Statistic SDC (N = 67) MTB (N = 67)a Differenceb P valuec
VITA classical shade guide
Shade change Day 90 LS mean (SE) −0.77 (0.22) 0.47 (0.22) −1.23 (0.31) .0001
95% CL −1.20, −0.33 0.03, 0.91 −1.85, −0.62
P valueb .0007 .0370
VITA bleached guide
Shade change Day 90 LS mean (SE) −0.29 (0.12) 0.15(0.12) −0.43 (0.17) .0108
95% CL −0.52, −0.05 −0.09, 0.38 −0.77, −0.10
P valueb .0162 .2216

Parametric ANOVA Model: Result = Phase 2 Trt (DiamondClean or MTB) + Phase 1 Trt (Zoom WhiteSpeed or Opalescence Boost) + Phase 1-by-Phase 2 Trt
Interaction + error.
a
There were 66 subjects in MTB group at Day 90.
b
Diff. Mean (SE) = Mean (SE) of the treatment difference. 95% CI and P value from t test of treatment difference.
c
P value is based on a ANOVA model F test (Ho: No difference between the phase 2 treatments).

treatment. Thus far, however, direct research on such assumptions
has been limited.
The outcomes reported here provide the basis for a number of con-
clusions. First, a lower dose peroxide-based bleaching system, PZW at
25% H2O2, in the presence of LED light activation, was shown to pro-
duce higher reductions of ΔE and shade than a higher dose 40% H2O2
counterpart, UOB. Thus, we rejected our first null hypothesis. At the time
points immediately following, at Day 7 and at Day 30, ΔE, as assessed
per the VES device, was significantly improved for PZW compared to
UOB. The differences were consistently evident for b* values at all the
three time points (Table 1), indicating the efficacy in reducing yellowness
of the tooth color. Significant differences were also observed, in favor of
PZW, for both the VCS and VBG shade guide assessments at immedi-
of the present study are consistent with these outcomes and add to
the body of evidence that power tooth brushing can help maintain
and extend the longevity of tooth shade improvement from chair-side
bleaching.
Both chair-side bleaching regimens were safe to use. As expected,
tooth sensitivity was an observed side effect. However, the incidence
overall was low (the highest reported incidence was at Day 7 with
17.9% of PZW and 20.6% of UOB subjects reporting an incidence of
sensitivity) as was the severity, with only one subject out of
134 reporting a sensitivity event of “moderate.” It has been suggested
that use of bleaching gels of a higher H2O2 concentrations will result
in an increase in the risk of tooth sensitivity, and in certain patients,
the sensitivity can be significant, occurring in the form of a reported

ately and 7 days following chair-side bleaching, though not at Day 30. “shock.”38 In the present study, where high-dose H2O2 was utilized,
These findings are consistent with publications reporting that the incidence and severity of tooth sensitivity was low for both PZW

bleaching gels of low H2O2 concentrations, with or without added light, and UOB, indicating that both products were generally well-tolerated.

heat, or nonthermal atmospheric pressure plasma, were highly effec- It is important to be cautious when interpreting the clinical signifi-

tive.31,32 A recent study reported that the whitening strip with light cance of the statistically significant differences detected between the
two in-office power bleaching systems. As shown in Tables 1 and 2, the
exposure for the last 5 minutes of the total contact time of 60 minutes
differences in numerical ΔE and shade changes between the two systems
was more efficacious in improving tooth color than the strip alone, indi-
are relatively small and tend to dissipate with time. Conversely, such
cating potential benefit of light to enhance tooth whitening efficacy.33
immediate and short-term advantages of additional bleaching efficacy
Second, with respect to the effect that power tooth brushing has
may be desirable by certain patients. It is the practitioner's responsibility
on the maintenance of chair-side bleaching, this study demonstrated
to adequately inform the patient of the differences, including bleaching
that SDC powered toothbrush maintained bleached tooth shade sig-
efficacy, among available bleaching options.
nificantly better than manual tooth brushing, as assessed by VCS and
VBG, irrespective of which bleaching modality was initially utilized. A
difference in color per VES measurement, however, was not detected.
6 | CONC LU SIONS
Therefore, we partially rejected our second hypothesis. While power
toothbrushes have become popular in recent years, there has been Within the limitations of this study it can be concluded that (1) both
resistance to daily use of power tooth brushing due to concerns with chair-side tooth bleaching regimens were effective and safe to use;
potential harm to enamel or to cause gingival recession. The results of (2) tooth bleaching with PZW showed greater change in overall color
two recent studies have shown that electric, sonic or other powered and shade, than UOB at Day 7; (3) SDC maintained bleached tooth
toothbrushes, regardless of mechanism of action, are as safe on the shade significantly better than MTB.
enamel and gingiva as a manual toothbrush.34,35 Prior research has
also established that power brushing removes more tooth surface
stains than manual tooth brushing, regardless of toothpaste used.36 In CONFLIC T OF INT E RE ST
addition, power tooth brushing has been shown to produce a measur- The authors do not have any financial interest in the companies
able effect on the maintenance of bleached tooth color.37 The findings whose materials are included in this article.
8 LEE ET AL.
ACKNOWLEDGMENT
The study was supported by grant #2120097 from Philips Oral
Healthcare.
ORCID
Sean S. Lee https://orcid.org/0000-0001-5583-9653
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How to cite this article: Lee SS, Kwon SR, Ward M,
Jenkins W, Souza S, Li Y. A 3 months clinical evaluation com-
paring two professional bleaching systems of 25% and 40%
hydrogen peroxide and extended treatment outcome using a
power versus a manual toothbrush. J Esthet Restor Dent. 2018;
1–8. https://doi.org/10.1111/jerd.12440