whitening

treatment
Incidence of
tooth sensitivity after home
MICHAEL G. JORGENSEN and WILLIAM B.
CARROLL
J Am Dent Assoc 2002;133;1076-1082

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C O S M E T I C
CARE

& RESTORA TIVE

A B S T R A C T
Background. A potential side
effect of dentist-dispensed home
toothwhitening systems is tooth
sensitivity. The authors

Incidence of tooth
sensitivity after
home whitening
treatment
MICHAEL G. JORGENSEN, D.D.S.;
WILLIAM B. CARROLL, D.D.S.

uring the past several years, patients

have become increasingly interested in
the esthetic benefits available from
dental treatment. In periodontics, esthetic
outcomes can be enhanced with crown
lengthening, edentulous
ridge augmentation or root coverage by means of a
variety of surgical
Restorative
techniques.1,2
procedures
that modify the shape, position or shade of
teeth are
used widely to accomplish esthetic 3,
4 When
goals.
a
change in tooth position is desired, orthodontic
treatment may be preferable to
invasive
procedures.
Patie restorative
Nonrestorative
nts
procedures such as enamel
conside
microabraring
sion5 bleaching
and tooth6
are
popular
home alternatives to restorative treatment
whiteni when the goal is to achieve a lighter
ng shade of enamel. Internal bleaching
treatment of endodontically treated teeth is
should be done to reverse the darkening that
advised frequently occurs in conjunction with
pulpal necrosis. Bleaching of vital
that mild
teeth has been performed on a
tooth limited basis in the dental office for
sensitivity many years.7-9
is a
Recently, whitening systems
common used by patients at home have
side effect become increasand that
severe
tooth

conducted a randomized
prospective double-blind
study to determine the
incidence of tooth sensitivity after home
whitening
C
treatment.
Methods. Fifty adult subjects used a
gel containing 15 percent carbamide
peroxide and 0.11 percent fluoride ion;
an additional 50 adult subjects used a
placebo gel daily for four weeks. Each
subjects plaque index score, gingival
recession status, caries status, cur- rent
dentifrice and smoking history were
recorded at baseline. The researchers
evalu- ated sensitivity weekly by
interview for four weeks.
Results. Fifty-four percent of subjects
in both test and control groups reported
mild sensitivity; 10 percent of test
subjects and 2
percent of control subjects reported moderate
sensitivity; 4 percent of test subjects and no
control subjects reported severe sensitivity.
Sensitivity decreased with time; by the
second week, no severe sensitivity
was reported, and by the fourth
week, no moderate sensitivity was reported. The
authors found a statistically significant
positive correlation between reported sensitivity and gingival recession. They found no
statistically significant correlations
between sensitivity and any of the other
recorded parameters. Conclusions.
Mild tooth sensitivity can be expected
in approximately one-half of patients who
undergo home whitening treat- ment
using the gel studied. Approximately 10
percent of patients may experience
moderate sensitivity, and 4 percent of
patients may experience severe
sensitivity for one to two weeks. Patients
with gingival recession

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sensiti
vity
occasion
ally
occu
rs.
dental

1013
ingly
However,
popular.
toothwhitening procedures may adversely

affect both
hard

1416

and soft17- tissue

20
s

tivity during home whitening treatment.

Clinical Implications. Patients consid-

in the oral cavity, as well as the

ering home whitening treatment should be

pulp,

advised that mild tooth sensitivity is a

although when they are

performed properly, their effects generally are mild
and
transient. Mucosal irritation often is related to tray
design or improper application of bleaching
agents. Adjustment of the tray or modification of
the technique used to apply the agent generally
eliminates the irritation.

1076
2002

appear more likely to experience tooth sensi-

2123

JADA, Vol. 133, August

common side effect and that severe

tooth sen- sitivity occasionally occurs. If
gingival reces- sion is present, the
probability of tooth sensi- tivity
increases, and tooth sensitivity tends to
decrease as treatment progresses.

Copyright 2002 American Dental Association. All rights reserved.

C O S M E T I C
R E S TOR ATI V E CA RE

One commonly reported potential side

effect of home-use whitening systems is
tooth sensitivity, which usually is mild and
transient, but occasion- ally may cause
significant discomfort. To date, only
anecdotal reports and retrospective studies
have addressed tooth sensitivity after
whitening treatment.13,18,20,21 We conducted a
randomized prospective double-blind study
to determine the incidence of tooth
sensitivity after home whitening treatment.
We hoped that data obtained as a result of
this investigation could enhance dental
practitioners ability to more knowledgeably
discuss the risks and benefits of home
bleaching with their patients.

&

weight/weight fluoride ion], Ultradent Products Inc.,

South Jordan, Utah) or identically packaged
placebo gel (glycerin, U.S.P.) obtained from the
manufacturer. Using a computerized randomiza-

MATERIALS AND METHODS

This clinical investigation was approved by

the scientific review committee and by the
committee for the protection of human
subjects at the Naval Medical Center, San
Diego. Subjects were recruited from among
patients receiving care at the dental
department at the Naval Medical Center.
After a pilot study in which three of 10
subjects engaged in home whitening
treatment experienced moderate sensitivity,
we determined the appropriate sample size
using power analysis (= .05). One hundred
adult dental patients par- ticipated in the
study. As recommended by the manufacturer,
pregnant patients were not enrolled as
subjects.
After obtaining written informed consent
from each subject, the principal investigator
(W.C.) performed the clinical examination,
fabricated a custom bleaching tray with
reservoirs and instructed the subject on use
of the system and on the data collection
method. Subjects were instructed to apply
only enough gel to fill the buccal reservoir
space in the tray and to wear the tray for one
three- to four-hour period daily.24 Parameters
recorded at baseline included the subjects
age, sex, plaque index score,25 gingival
recession status, caries status, dentifrice
being used and history of tobacco use.
Subjects were instructed to continue their
customary oral hygiene regimen and to
continue using their cur- rent dentifrice. The
associate investigator (M.J.) dispensed kits
containing either bleaching gel (Opalescence
F1 [5 percent carbamide peroxide with 0.11
percent1,100 parts per million
JADA, Vol. 133, August 2002
1077
Copyright 2002 American Dental Association. All rights reserved.

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C O S M E T I C

&

REST
O R A T I V E(dBase
C A R E randomization
tion
program
program, manufactured at the time of
the study by Borland Software Corp.,
Scotts Valley, Calif., now manu- factured
by dBase Inc., Vestal, N.Y.), we randomly determined the contents of the
kits. We evaluated sensitivity by
interviewing each subject on a weekly
basis for four weeks and recorded it
using the following scale:
dno changes noted;
d1 = mild sensitivityslight change
noted, no interference with function,
well-tolerated;
d2 = moderate sensitivitydefinite
change noted, some interference with
function, necessity of avoiding certain
foods;
d3 = severe sensitivitysubject
considered dis- continuing treatment,
major interference with function,
necessity of avoiding many foods.
The principal investigator conducted
all weekly evaluations; neither the
subject nor the principal investigator
was aware of the nature of the gel being
used. After data collection was
completed, the code was broken, and
the principal investi- gator issued
bleaching gel to subjects who had used
a placebo, so that they might
accomplish tooth whitening.

1078

RESULTS

Demographic and baseline data. Subject

demographics and baseline data are
summarized in the table. Fifty-seven women
and 43 men ranging from 19 to 55 years of
age took part in the study.
Plaque index scores. Plaque index scores
varied from 2 to 40 percent. One subject in
the car- bamide peroxide group had a plaque
index score of 40 percent, and another
subject in that group had a plaque index
score of 30 percent; all other subjects had
plaque index scores of less than or equal to
20 percent, and the average plaque index
score for all subjects was 9.5 percent.
Gingival recession status. Twenty-eight subjects had no gingival recession; 52 subjects
had at least one tooth with 1 millimeter of
gingival recession; 16 subjects had at least
one tooth with 2 mm of gingival recession;
four subjects had at least one tooth with 3
mm of gingival recession. We saw no
recession greater than 3 mm. The magnitude
(0-3 mm) and distribution of recession was
similar for the carbamide peroxide and
placebo groups.
Dental caries status. We detected no dental
caries in any subject.
Dentifrices used. Fifteen different dentifrices

JADA, Vol. 133, August 2002

Copyright 2002 American Dental Association. All rights reserved.

TABLE

CHARACTERISTICS OF SUBJECT POPULATION.

PATIENT
S

NUMBER

AGE
RANGE
(YEARS
)

RANGE OF
PLAQUE
INDEX
SCORES
(% OF TEETH
2-40

GINGIVA
L
RECESSI
ON
(mm)
0-3

SMOKIN
G
HISTORY
(N)

Female

57

19-55

Male

43

21-51

2-30

0-3

19-55

2-40

0-3

14

100

NUMBER OF PATIENTS

OVERALL

10

* As measured with the Plaque Control Record (OLeary and colleagues25).

mm: Millimeters.

40

20

TOOTH SENSITIVITY

15% Carbamide Peroxide

Placebo Gel

Figure 1. Subjects self-rated tooth

sensitivity after one week of whitening or
placebo gel. 0: No sensitivity. 1: Mild
sensitivity. 2: Moderate sensitivity. 3:
Severe sensitivity.

were recorded, all containing some type of

fluo- ride; seven subjects reported using a
tooth- whitening dentifrice.
Tobacco use. Fourteen subjects reported a
his- tory of tobacco use (eight subjects from
the car- bamide peroxide group, six subjects
from the placebo gel group).
Sensitivity status. No existing tooth
sensitivity was reported at baseline.
Figures 1 through 4 summarize the
findings from weekly follow-up evaluations.
All subjects (50 using carbamide peroxide gel
and 50 using a placebo gel) completed the
study, and all reported using the gel provided
as directed.

After one week of home whitening

treatment using the carbamide peroxide gel
(Figure 1), 27 (54 percent) subjects reported
mild sensitivity; 27 (54 percent) subjects
using the placebo gel also reported mild
sensitivity. Four (8 percent) sub- jects using
the carbamide peroxide gel and one (2
percent) subject using the placebo gel
reported moderate sensitivity. Two (4
percent) subjects using the carbamide
peroxide gel and no subjects using the
placebo gel reported severe sensitivity.
Seventeen (34 percent) subjects using the
car- bamide peroxide gel and 22 (44 percent)
of those using the placebo gel reported no
sensitivity.
After two weeks of treatment (Figure 2), 27
(54 percent) subjects using the carbamide
peroxide gel and 24 (48 percent) subjects
using the placebo gel reported mild
sensitivity. Three (6 percent) subjects using
the carbamide peroxide gel and no subjects
using the placebo gel reported moderate
sensitivity. No subjects in either group
reported severe sensitivity after two weeks.
Twenty (40 percent) subjects using the
carbamide peroxide gel and 26 (52 percent)
of those using the placebo gel reported no
sensitivity.
After three weeks of treatment (Figure 3),
18 (36 percent) subjects using the carbamide
per- oxide gel and 14 (28 percent) subjects
using the placebo gel reported mild
sensitivity. One (2 per- cent) subject using the
placebo gel and no subjects using the
carbamide peroxide gel reported mod- erate
sensitivity. No subjects in either group
reported severe sensitivity after three weeks.
Thirty-one (62 percent) subjects using the
car- bamide peroxide gel and 36 (72 percent)
of those using the placebo gel reported no
sensitivity.

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At the conclusion of the study, after four

weeks of treatment (Figure 4), four (8 percent)
subjects using the carbamide peroxide gel and

three (6 percent) subjects using the placebo

gel reported

NUMBER OF PATIENTS

NUMBER OF PATIENTS

40

40

20

20

0
0

TOOTH SENSITIVITY
15% Carbamide Peroxide

Placebo Gel

Figure 2. Subjects self-rated tooth

sensitivity after two weeks of whitening
or placebo gel. 0: No sensitivity. 1: Mild
sensitivity. 2: Moderate sensitivity. 3:
Severe sensitivity.

mild sensitivity. No subjects in either group

reported either moderate or severe tooth
sensi- tivity after four weeks. Forty-six (92
percent) sub- jects using the carbamide
peroxide gel and 47 (94 percent) of those
using the placebo gel reported no sensitivity.
Statistical analysis. We applied multiple
logistic regression analysis to baseline
parame- ters and sensitivity data. We found
no significant differences between sensitivity
associated with 15 percent carbamide
peroxide gel and that associ- ated with
placebo gel. We did see a significant
correlation between gingival recession and
sensi- tivity (P < .003, P < .001, P < .001 and
P < .002 at
one, two, three and four weeks, respectively).
Figure 5 illustrates the percentage of patients
reporting sensitivity based on the amount of
gin- gival recession recorded at baseline. No
other recorded parameters showed
statistically signifi- cant correlations to
sensitivity.
DISCUSSION

A substantial component of contemporary

den- tistry is esthetic treatment. While this
may at times necessitate restorative
procedures, the potential adverse
consequences must be weighed against
expected benefits. Esthetic restorative

TOOTH SENSITIVITY
15% Carbamide Peroxide

Placebo Gel

procedures often involve restorations with subgin- gival

margins, which have been shown to promote bacterial plaque
accumulation26 and, thus, have a

NUMBER OF

40
Figure 3. Subjects selfrated tooth sensitivity after
three weeks of whitening
or placebo gel. 0: No
sensitivity. 1: Mild
sensitivity. 2: Moderate
sensitivity. 3: Severe
sensitivity.

20

Figure 4. Subjects self-rated tooth

sensitivity after four weeks of whitening
0
or placebo
gel. 0: No sensitivity. 1: Mild
sensitivity.
3:
0 2: Moderate
1
2sensitivity.
3
Severe sensitivity.

TOOTH
detrimental effect
onSENSITIVITY
periodontal health.27 It
therefore is in the patients best interest to
receive nonrestorative
esthetic treatment
15% Carbamide Peroxide
Placebo Gel
when- ever such noninvasive or minimally
invasive pro- cedures will provide an
acceptable esthetic out- come.
Nonrestorative esthetic procedures may
involve orthodontic alignment of
malpositioned

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PATIENTS REPORTING SENSITIVITY (PERCENTAGE)

100

80

6
0

4
2
0
0
1

WEEKS OF
TREATMENT
Figure 5. Percentage of patients
based on gingival reces- sion.

whitening should be informed of

its potential risks and benefits.
Dentist- supervised home-use
whitening sys- tems have been
shown to be safe and effective,
Millimeters of Gingival Recession
resulting in only mild, transient
changes in gingival and pulpal
tissues. An agent commonly
0
used for home whitening is car1
bamide peroxide in
concentrations of 10 to 20
2
percent. Adverse effects of this
3
treatment
may
include
gingival
irritation and
tooth
sensitivity.
Gingival irritation can be minimized
by
reducing contact of the bleaching
gel
with gingival tissue. This is best
D
accomplished by adding a thin
o
layer
of acrylic to the facial surfaces of
w
4
teeth on the plaster cast before
nl
adapting the tray material,
oa
thereby
creating a reservoir for the gel
de
(Figure 6). This is one important
reporting sensitivity
d
reason why custom bleaching
fr
trays provided by a dentist are
safer and
o
deciding to pro- ceed with treatment, patients
m
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Figure 6. A thin layer of acrylic is added

to facial surfaces of teeth before the
bleaching tray is adapted, thus cre- ating
a reservoir for the bleaching gel.

teeth, as well as measures designed to

lighten the shade of enamel.
Tooth-whitening treatment has become
very popular in recent years. Before

more effective than over-thecounter trays. In addition, when the

whitening process is super- vised,
patients can be trained to avoid
using excessive gel and
consequently minimize gingival
irritation further.11
Patients should be advised that
some transient tooth sensitivity may
be experienced during the whitening
treatment. Our finding that
sensitivity tends to occur early in
treatment and decrease as
treatment continues is in agreement
with find- ings in previous
reports.13,20,28 Using 10 percent
carbamide peroxide bleaching gel,
Haywood and colleagues18 evaluated
side effects using a patient log and

one follow-up examination after six weeks.

Fifty-two percent of their subjects recorded
some tooth sensitivity, the severity of which
was not reported. Tam28 evaluated 24 subjects using three different brands of 10
percent carbamide peroxide gel in a crossmouth study; 64 percent of the subjects
reported sensitivity in their daily log. The
majority of the sensitivity reported by our
subjects was mild and occurred with the
carbamide peroxide gel, as well as with the
inert placebo gel. This sensitivity may have
been due simply to the presence of the gel
itself in close contact with the teeth, and the
disappear- ance of sensitivity may have been
due to sensory accommodation.
It is possible that subjects in this study,
including those using the placebo gel,
performed

B
Figure 7. A patient who underwent dentist-supervised home-use whitening, before (A)
and after (B) treatment. This patient reported moderate tooth sensitivity during the
first two weeks of daily application of 15 percent carbamide peroxide gel with 0.11
percent fluoride ion. Patients with gingival recession, as seen here in multiple sites,
were more likely to report tooth sensitivity.

overzealous tooth brushing as a result of the

Hawthorne effect: people participating in
clinical trials may brush more often and more
vigorously, and this may have contributed to
the sensitivity reported by both the test and
control subjects.
With the exception of one subject who
reported moderate sensitivity with the
placebo gel on one occasion, moderate or
severe sensitivity was asso- ciated only with
the carbamide peroxide gel and likely was
related to the bleaching agent. The
subsequent decrease in sensitivity as
treatment progressed may have been due to
the fluoride con- tent of the bleaching gel,
since topical fluoride has been shown to
reduce sensitivity29 and this reduc- tion in
sensitivity tends to occur after a week or
more of application.30
All subjects in this study completed the
four- week course of treatment, after which
only 8 per- cent of subjects using the
carbamide peroxide gel and 6 percent of
subjects using the placebo gel reported mild
sensitivity. This is in agreement with previous

reports indicating that home whitening treatment

supervised by a dentist may result in sensitivity
but that this side effect does not prevent the
patient from successfully com- pleting the full
course of treatment. In comparing various
parameters with reported tooth sensi- tivity, we
found that only gingival recession had a
statistically significant relationship (Figure 7).
This is in contrast to a report by Haywood,11 but is
consistent with findings by Addy and colleagues,31 who found a significant correlation
between gingival recession and sensitivity in a
clinical study of pre-existing dentinal hypersensitivity. It would seem prudent to advise patients
who have gingival recession and are contem-

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plating home whitening treatment that

they may be more likely to experience
sensitivity than would people without
gingival recession.
In general, it is reasonable to advise
all patients contemplating home
whitening treat- ment that there is
approximately a 50 percent chance that
they will experience some mild sensitivity, a 10 percent chance of moderate
sensitivity and a slight (4 percent)
chance of severe sensi- tivity. Patients
may be assured, however, that should
this side effect occur, it will tend to
decrease as treatment progresses and
likely will not prevent them from
completing the full course of whitening
treatment.
Single-episode tooth whitening
procedures per- formed in the dental
office have become popular during the
past few years.32 Currently, limited data

exist regarding the incidence and severity of

tooth sensitivity after this one-time
treatment.33,34 Further clinical investigation of
in-office whitening procedures could provide
additional information that would be valuable
to patients who are considering various
treatment options.
CONCLUSIONS

Home whitening treatment supervised by a

den- tist using a gel containing 15 percent
carbamide peroxide and 0.11 percent fluoride
delivered via custom bleaching trays with
reservoirs may cause transient mild tooth
sensitivity in 54 percent of patients, transient
moderate tooth sensitivity in 10 percent of
patients and transient severe sensi- tivity in 4
percent of patients. Patients with gin- gival
recession appear to be more likely to experience tooth sensitivity during home whitening
treatment. Tooth sensitivity tends to decrease
as

Dr. Jorgensen is an
associate professor
of clinical
dentistry, Division
of Primary Oral
Health Care, University of Southern
California, School
of Dentistry, 925 W.
34th

Dr. Carroll is a
captain, Dental
Corps, U.S. Navy,
and the director,
Gen- eral Practice
Residency, Naval
Medical Center, San
Diego, Calif.

treatment progresses and is

not likely to
prevent
patients from
success- fully
completing a
full course of
home
whitening
treatment.

The opinions or
assertions contained herein are those of the
authors and are not to be construed as
official or as reflecting the views of the
U.S. Department of the Navy.

12.Settembrini L, LoPresti J, Scherer W. Removal of enamel surface

stains with at-home vital bleaching. Am J Dent 1995;8(2):73-4.
13.Mokhlis GR, Matis BA, Cochran MA, Eckert GJ. A clinical evaluation of carbamide peroxide and hydrogen peroxide whitening
agents during daytime use. JADA 2000;131:1269-77.
14.Ernst CP, Marroquin BB, Willershausen-Zonnchen B. Effects of
hydrogen peroxide-containing bleaching agents on the
morphology
of
human
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Quintessence
Int
1996;27(1):53-6.
15.McCracken MS, Haywood VB. Demineralization effects of 10 percent carbamide peroxide. J Dent 1996;24:395-8.
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Zalkind
M. Histochemical analysis of dental hard tissues following
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St., Los Angeles,
Calif. 90089-0641,
email
jorgensm@usc.ed
u. Address reprint
requests to Dr.
Jorgensen.

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