For some time, there has been consistent consumer demand for whiter, brighter teeth and an attractive smile.1-3 Professionally administered (in-office) tooth whitening, also known as dental bleaching, remains a popular esthetic procedure and can be performed using a wide range of techniques and application protocols. Another common approach is at-home whitening with custom-fitted trays, which patients use to apply professional-strength bleaching gel (for use at night or during the day). Numerous over-the-counter (OTC) whitening products (e.g., strips, gels, rinses, chewing gums, or paint-on films) are also widely available for self-application at home.4
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Extrinsic vs. Intrinsic Stains
Tooth (and dental) discoloration are terms used to describe any change in the color or translucency of a tooth,1 as well as discoloration in multiple teeth or the entire dentition. Tooth discolorations are typically classified as extrinsic, intrinsic, or a combination of both types.5
Extrinsic stains commonly result from an accumulation of colored compounds on enamel. Extrinsic discoloration is primarily associated with environmental factors or individual behaviors, such as tobacco use, exposure to metal salts (e.g., iron or copper), or the consumption of highly pigmented foods (e.g., dark fruits) or beverages (e.g., red wine, coffee, tea, or cola drinks).1, 6-11
Extrinsic tooth stains vary widely in color and severity, and can be exacerbated by lifestyle habits (e.g., smoking or chewing tobacco), poor oral hygiene, or frequent consumption of pigmented food or beverages.12, 13 A wide range of extrinsic stains can be effectively reduced with mechanical interventions such as brushing with a whitening toothpaste or professional prophylaxis.6, 7, 14 Some OTC whitening products (e.g., toothpastes, chewing gums) are effective primarily in removing extrinsic (surface) stains on enamel, and will not have a significant impact on intrinsic stains or the intrinsic color of the tooth.4, 15
Intrinsic stains occur inside the tooth (within the enamel or the underlying dentin), and can arise due to systemic causes such as genetic disorders (e.g., dentinogenesis imperfecta, amelogenesis imperfecta) or local factors during tooth development or after eruption (e.g., fluorosis).1, 16, 17 Aging is another common etiology of intrinsic discoloration. With increasing age, enamel becomes more translucent and thinner, which allows the yellower dentin to show through and the overall tooth color may darken.1, 18 Other causes of intrinsic discoloration include certain antibiotic use in childhood (e.g., tetracycline),19 caries, amalgam restorations, and pulpal hemorrhage, decomposition or necrosis.5, 7, 20 Intrinsic discoloration can also occur with prolonged use of antiseptic mouthrinse (e.g., chlorhexidine rinse).21
Whitening Agents
Reducing intrinsic stains involves a chemical reaction that changes the color of the tooth. The most common ingredients used in bleaching are carbamide peroxide and hydrogen peroxide, which are used at different concentrations depending on the products or regimens used.22
The bleaching action in chemically induced whitening is due primarily to the effects of carbamide peroxide, which releases about one-third of its content as hydrogen peroxide, a strong oxidizing agent.23, 24 Hydrogen peroxide diffuses easily through interprismatic spaces in the enamel, allowing for passage from enamel and dentin to pulp within 15 minutes of exposure.25, 26 The bleaching process is generally believed to occur when reactive oxygen molecules (generated from hydrogen peroxide) interact with organic chromophores (colored compounds) within enamel and dentin through a chemical oxidation process, which is influenced by various environmental factors (e.g., pH, temperature, light).17, 25, 27
The extent of whitening attained through bleaching may be influenced by the type of intrinsic stain being addressed. For example, brown stains due to fluorosis or tetracycline28, 29 may be more responsive to bleaching than white stains associated with fluorosis or orthodontic treatment, which may appear less noticeable as the background of the tooth lightens.30 The type of stain also can affect the length of and/or number of treatments required to arrive as close as possible to the desired result. For example, although stains due to tetracycline may be diminished, treatment can require three to four months of nightly treatment (on average).28, 31
Patient Considerations and Preferences
Tooth whitening is a common elective procedure and a popular, less-invasive aesthetic treatment for patients seeking to enhance their smile and appearance. A clinical exam prior to the start of tooth bleaching procedures, with radiographs and other screening and diagnostic tests as appropriate, can help diagnose various factors contributing to the patient’s tooth discoloration.32 A standard dental exam, beginning with a health and dental history, may include questions about the patient’s perception of the cause of the dental discoloration, as well as allergies (which may include ingredients in bleaching materials), and any past or recent history of tooth sensitivity.32, 33
Patient dentition characteristics also influence the safe provision of care and the treatment’s level of success in whitening vital teeth. Patients who have tooth-colored restorations (including crowns or implants) should be aware that only natural teeth will be affected by the bleaching agent and treatment could result in differences between natural teeth and restorations, which will not change color.28 The American Academy of Pediatric Dentistry discourages full-arch cosmetic bleaching for child and adolescent patients in the mixed dentition and primary dentition.34 Additionally, some research suggests that bleaching protocols may alter the surface roughness of enamel, which may also reduce the shear bond strength between enamel and composite and ceramic restorative materials.35
Products Directly Available to Consumers
Bleaching compounds in over-the-counter whitening products are peroxide-based and typically contain carbamide peroxide or hydrogen peroxide at lower concentrations than in-office or dentist-prescribed, at-home bleaching techniques. A variety of OTC options are available with products that include toothpastes, whitening strips, and gels painted directly on teeth or delivered in trays. Products that bear the ADA Seal of Acceptance (a voluntary program for OTC oral care products), indicating that the company has demonstrated that the product meets ADA Seal Program requirements for safety and effectiveness when used as directed, include toothpastes and whitening strips.
Whitening toothpastes primarily rely on abrasives for mechanical removal of extrinsic surface stains, though some contain low levels of peroxide to help lighten tooth color.7, 36, 37 A systematic review found limited evidence that whitening dentifrices had similar efficacy to paint-on gel but less efficacy than whitening strips, with comparable adverse effects (e.g., sensitivity, oral irritation).38 Most whitening strips rely primarily on peroxide to bleach teeth.33, 39
In-Office Procedures and Products Available Through Dentists
Examples of products available through dentists include gels delivered in custom-made trays, either intended for at-home use or applied as an in-office treatment. In-office whitening treatment may involve application of a peroxide-containing gel, used with or without a light intended to accelerate and enhance the bleaching process (known as a light-activated system).40 Another in-office bleaching procedure, known as “power bleaching,” uses concentrated solutions of hydrogen peroxide in water (with or without light activation), which may be applied for up to 30 minutes.17
Dentist-supervised whitening approaches include at-home and in-office options (note: whitening products supplied by dentists for use at home or applied by dentists in the office are considered “professional products,” and are not eligible for the ADA Seal of Acceptance). At-home whitening with custom trays involves whitening gel placed in trays by the patient at home. The trays are made in the office to fit comfortably and minimize contact of the gel with the patient’s gingiva. Peroxide concentration in at-home systems typically ranges from 10% to 38% carbamide peroxide and treatment times are dictated primarily by the concentration used.41 A systematic review by de Geus et al. found daily treatment times ranging from 2 to 10 hours for periods of 6 to 28 days.42
Other in-office techniques for removing extrinsic stains include rubber-cup prophylaxis and enamel microabrasion, which may be completed before the provision of other in-office bleaching treatments that use gels with high peroxide concentrations or light-activated bleaching systems.15 Microabrasion uses an abrasive slurry (e.g., acidic gel with abrasive particles) to remove thin outer layers of the enamel surface.15 Microabrasion may also be supplemented by chemically induced whitening for enhanced stain removal and improved patient satisfaction with esthetic outcomes. This procedure is typically limited to treatment of extrinsic stains or defects that do not extend beyond the enamel.15, 43 Overall, the removal of intrinsic stains within the dentin is considered near impossible when using an external whitening procedure (i.e., chemical and/or mechanical) whitening treatments.17
Whitening of non-vital discolored teeth may be performed through intracoronal (internal) bleaching, a procedure that uses carbamide peroxide, hydrogen peroxide, or sodium perborate to provide adequate internal bleaching of non-vital teeth.44 In rare instances, non-vital tooth bleaching has been associated with reports of external cervical resorption, but the overall incidence of this adverse effect is not considered common.45, 46
Treatment Considerations
Examples of whitening treatment considerations may include the patient lifestyle, socioeconomic status, and present oral health.32, 33 Since restorative materials generally do not change color, identifying and documenting existing tooth restorations as part of the dental examination can help promote and achieve an acceptable tooth bleaching outcome. Restorations can also be a cause of tooth discoloration: metallic and other restorative materials on the lingual or occlusal surface of the teeth may influence tooth color significantly. Patient expectations may not be met or may be unrealistic without addressing cosmetic issues with existing restorations.15
While OTC whitening products tend to be less expensive than at-home or in-office approaches, there is often a time trade-off in that OTC products may take significantly longer than either of the other options to achieve similar levels of whitening. Auschill et al. found that an OTC bleaching technique took 16 days to achieve the whitening level of a seven-day, at-home tray system and a one-day, in-office procedure.47
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Sensitivity
One common adverse effect of OTC or dentist-dispensed, tray-based whitening is tooth sensitivity, which can be more prevalent with higher concentrations of active agents but is typically mild and transient.1 Risk of temporary dental sensitivity is associated with all forms of bleaching,42, 48-50 possibly due to inflammation of the pulp as a result of peroxide exposure during the procedure.51
Regarding dental hard tissues, transient mild to moderate tooth sensitivity can occur in up to two-thirds of users during early stages of bleaching treatment.52 With whitening strip or tray-based treatments, sensitivity may develop within two to three days after starting the program and usually resolves by the fourth day post-treatment.48
Factors that may influence the development or extent of tooth sensitivity associated with bleaching include concentration of carbamide or hydrogen peroxide, the presence of adhesive restorations53 or the contact time and intensity and duration of light use.48, 54, 55 However, a recent systematic review of in-office whitening found use of lower concentrations of hydrogen peroxide resulted in less tooth sensitivity and greater objective color change.56
A variety of approaches to prevent bleaching sensitivity have been explored, such as pretreatment use of nonsteroidal anti-inflammatory drugs57, 58 and pretreatment application of 5% potassium nitrate and 2% sodium fluoride gel.59, 60 Further research is needed to confirm the efficacy of these approaches in reducing tooth sensitivity.
Gingival Irritation
Gingival irritation can result from contact with peroxide-based gels when whitening strips or any gel-based product is used for whitening. It is typically due to poor-fitting trays or improper application of the protective barrier or gel.22, 48 Li suggests that use of local anesthesia be avoided during in-office bleaching so that patients can detect any burning sensations, which could indicate gel seepage through the barrier, and that patients be instructed to alert the dentist to any discomfort during the procedure so that integrity of the barrier can be checked.22
A Cochrane review on the use of home-based whitening products found that tooth sensitivity and oral irritation were the most common adverse effects, which were more prevalent at higher concentrations but also considered mild and transient.1 A comparative systematic review of tray-delivered carbamide peroxide gels versus hydrogen peroxide products (for at-home bleaching) found that both whitening systems had relatively equal levels of tooth sensitivity and gingival irritation.61 As with sensitivity, gingival irritation is typically transient and resolves shortly after completing the treatment.22 Additionally, a systematic review concluded that hydrogen peroxide-containing products used for tooth whitening do not appear to have carcinogenic effects on the oral mucosa.62
If you’ve been hesitant about using whitening strips and whitening kits to whiten your pearly whites in the past, now may be a perfect time to actually give them a go, Julie Cho, D.M.D., a general dentist in New York City, tells SELF. Many of us are (still) working remotely due to the ongoing coronavirus pandemic, so we have the time to experiment for a few days with teeth whitening kits like these—and can more closely monitor how they affect our teeth and (temporarily) thwart high-staining foods.
With so much variety, though, it’s hard to know how to find the best teeth whitening kit, whitening strips, or whitening toothpaste for you. Here’s what you need to know.
What causes teeth staining?
One of the most common causes of teeth surface stains is what you eat, Cho says. Things like blueberries, coffee, and red wine can stain your teeth, especially if you eat them frequently.
This kind of pigmentation is the kind that responds best to whitening agents, Mark S. Wolff, D.D.S., Morton Amsterdam Dean of the University of Pennsylvania School of Dental Medicine, tells SELF. There’s a colored molecule in these foods (called a chromogen) “that literally attaches itself to the outside of the tooth,” he explains. Whitening agents, which tend to be bleaching chemicals like carbamide peroxide or hydrogen peroxide, break up the chromogen so that it can be easily washed away.
But there are a ton of other things that can contribute to the discoloration on your teeth. Some teeth just naturally develop more color as they grow in, which tends to be yellowish, brown, or even reddish, Wolff says. Part of that is also determined by your genetics, Cho points out. These types of pigment are deeper in the tooth and generally require more aggressive whitening than over-the-counter options offer.
Other causes of teeth surface stains include medications (particularly tetracycline, which is known to give teeth a gray or purplish hue in some patients) and metals precipitating in the mouth (which might appear as black dots on the teeth after taking iron supplements, for instance). In both of these cases, over-the-counter whitening products aren’t likely to be effective, Wolff says, and you’ll have to get assessed by a dentist to figure out the best strategy to lighten your teeth.
Who should—and shouldn’t—use at-home teeth-whitening kits?
The most common side effect associated with whitening teeth is increased sensitivity, so people who already have sensitive teeth should use these whitening kits with caution, Cho says, and you may want to steer clear entirely. Not only can some bleaching agents strip some of the protective enamel from the teeth, Wolff warns, but they can also exacerbate any sensitivity related to gum recession.
However, this effect is usually temporary and will lessen after your treatment period is over. You can also minimize it by using a toothpaste for sensitive teeth while doing the whitening treatment, Cho says.
But home whitening kits and whitening strips are still a good place to start before getting in-office treatment. If you use an at-home kit and find that you still don’t have the results you want (and don’t develop too much sensitivity), you may be a good candidate for in-office whitening treatments, Cho says.
What should you know before using a home teeth-whitening kit?
Honestly, teeth-whitening kits won’t work super well for everyone. How well they work for you depends on a bunch of different things, including consistency. In-office treatments are done once with a high concentration of bleach. Home kits spread that out (usually over 10 to 14 days) and use a lower concentration of bleach, so it’s important to use them consistently for that amount of time if you want to see results.
Also, know that the whitening won’t last forever, Cho says. Even in-office results last between six months and two years, she says, which is a huge window. But ultimately, how long any whitening lasts “is dependent on your habits,” Wolff says. If you’re a heavy coffee drinker or smoker, or are genetically more prone to darker teeth, you may find your results don’t last as long. But no matter who you are, you should expect to need to repeat the process at some point if you still want your teeth to appear whitened.
On the flip side, you actually shouldn’t whiten your teeth continuously, Wolff says, because that can start to damage the teeth and actually make them look gray rather than white. Doing it once every six months to a year should be the limit, he says.
Remember that, unlike your natural teeth, devices like veneers won’t whiten, Cho says. And overall, you may not get the perfect gleaming shade of white you’re after. So it’s crucial to have realistic expectations for what your results might be, Wolff says. If you’re not happy with your results, you can chat with a dentist about what else you can do to whiten your teeth.
There’s also a ton of variety out there, so if you don’t like one teeth whitening kit, you can try others to find the best whitening kit for you. The American Dental Association (ADA) even has a voluntary seal program to indicate which products meet their standards, which Wolff recommends using as a guide when selecting a product.
Below, find recommendations for the best teeth-whitening products from our experts as well as teeth-whitening treatments and whitening toothpastes that have the ADA seal of acceptance. We’ve also included a few that are SELF Healthy Beauty Award winners, and several from brands such as Crest, Colgate, GLO, and more. You can largely buy all of these whitening products at Amazon, Target, or Walmart.
If you are looking for more details, kindly visit teeth whitening wholesale suppliers.
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