ORIGINAL CONTRIBUTIONS

CRITICAL SUMMARIES

Using light to enhance in-office vital bleaching may increase both efficacy and tooth sensitivity A critical summary of He L-B, Shao M-Y, Tan K, Xu X, Li J-Y. The effects of light on bleaching and tooth sensitivity during in-office vital bleaching: a systematic review and meta-analysis. J Dent 2012;40(8):644-653. Deborah S. Ray, DMD

Clinical question. Does the use of a light-activated system during in-office vital bleaching produce better bleaching effects or affect tooth sensitivity compared with the use of a nonlight–activated bleaching system? Review methods. The authors searched three databases without restriction regarding date or language. They also hand searched the reference lists in the studies they found that met their criteria for additional studies relevant to the question that met the inclusion criteria. They considered all randomized controlled trials (RCTs) and quasi-RCTs in which investigators compared lightactivated with nonactivated bleaching systems by using only parallel or split-mouth designs. The authors calculated the mean difference (MD) with a 95 percent confidence interval (CI) and set the heterogeneity significance at P < .1 for both the bleaching efficacy and tooth sensitivity data. The authors assessed all of the studies for bias by using the risk of bias criteria established by the Cochrane Collaboration.1 The authors excluded teeth with severe

staining owing to the use of tetracycline, fluorosis or discoloration due to endodontic treatment, as well as those with a history of bleaching treatment. There was no restriction on the type of light source. The same bleaching protocols were used in each study. The authors measured bleaching outcomes by means of visual (shade guide) or instrumental (digital imaging device/spectrophotometer) evaluation. They measured tooth sensitivity by means of visual analog scale, verbal scale or a percentage of participants with sensitivity. Main results. The authors identified 11 studies for their review. Investigators in all 11 studies compared bleaching efficacy, and in seven studies they compared tooth sensitivity as well. Of the 11 studies identified, five had low bias, four had moderate bias and two had high bias. They did not include studies with high bias in their final metaanalysis. To avoid heterogeneity, the authors separated the trials into two subgroups: those involving the use of high concentrations of HP (25-30 percent) and those involving the use

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of low concentrations of HP (15-20 percent). Investigators in two trials used low concentrations. The results of the trials in which high concentrations of HP were used showed no significant differences between the light-activated and nonactivated bleaching systems (MD, −0.39; 95 percent CI, −1.15 to 0.37; P = .32). The results of the subgroup analysis of the trials in which a low concentration of HP were used showed that the use of a light-activated bleaching system resulted in better bleaching efficacy (MD, −1.78; 95 percent CI, −2.30 to −1.26; P < .00001). In further analysis of results over time, the authors compared immediate effects (within one day), short-term effects (one-four weeks) and median-term effects (12-14 weeks) and found no difference in the results stated. Investigators in seven studies analyzed tooth sensitivity; in four, they used dichotomous data, and in three, they used continuous data. The authors reported no heterogeneity between the studies. They found that a higher likelihood of tooth sensitivity was associated with light-activated systems. They analyzed only immediate

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ORIGINAL CONTRIBUTIONS

sensitivity owing to the fact that a variety of desensitizing procedures were used after bleaching. Conclusions. Owing to the number of studies reviewed, there is inconclusive evidence to support

the use of light-activation systems to enhance the efficacy of high concentrations of HP. Light activation increases the risk of experiencing tooth sensitivity, and there is some limited evidence that it may be

helpful in increasing the immediate effect of lower HP concentrations. The authors did not did not report any sources of funding for the review or conflicts of interest.

COMMENTARY Importance and context. Tooth color is the primary reason for dissatisfaction with dental appearance, and tooth whitening is the most desired treatment.2,3 Patients also desire the most efficient and convenient method of whitening. In-office tooth bleaching systems purport to provide quick results, although tooth sensitivity can be an issue. The results of many studies of light-activated systems seem to be contradictory, and none of the investigators in the reviews assessed the results quantitatively. Strengths and weaknesses of the systematic review. The focus of this review was stated clearly. The authors searched three databases (MEDLINE, Embase and the Cochrane Central Register of Controlled Trials) to identify studies for inclusion in their review without restrictions for date or language. The authors, however, did not mention searching for unpublished studies or hand searching the reference lists of additional journal articles, nor did they contact experts in the field to help them identify additional studies. The inclusion and exclusion criteria were outlined clearly in a flow diagram. The authors included only RCTs or quasi-RCTs, and two independent reviewers reviewed all of the studies to determine if they should be included in the meta-analysis. If disagreements arose between the independent reviewers, they were settled through discussion or the inclusion of a third reviewer. The authors assessed individual studies for bias, although they did not establish subgroups of high and low concentrations of HP before they performed the data analysis. Strengths and weaknesses of the evidence. Although the authors of this systematic review suggested that the use of light activation may boost the effect of lower concentrations of HP and has little effect on use with higher concentrations of HP, the quality of the evidence should be considered limited. Approximately one-half (four of nine RCTs, 44.4 percent) of the included studies had moderate bias; two additional studies that were not included in the final analysis had high bias. Only three RCTs had adequate allocation concealment. The 11 studies involved a total of 211 patients, and the sample size within each study was relatively low—10 to 30 participants per study.

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Thus, the summary estimate of high- and low-HP concentrations exhibited wide confidence intervals, indicating imprecision in the results, and I2 test results indicated moderate heterogeneity (inconsistency) among study results. Another weakness and possible reason for the moderate heterogeneity was the inclusion of multiple types of light sources. No evidence was discussed regarding the differences in the efficacy of each light source. Implications for dental practice. The evidence to support the use of light activation with in-office vital bleaching is weak. More studies with larger sample sizes are needed to evaluate the efficacy of lightactivated systems, as well as different light sources, particularly when used with high concentrations of HP. The use of light activation, regardless of concentration of HP, does increase tooth sensitivity and should be used with caution, if at all, until the results of further studies confirm its efficacy. ■ doi:10.14219/jada.2014.76 Dr. Ray is an assistant professor and clinical team leader, Division of Restorative Dentistry, College of Dentistry, University of Kentucky, 800 Rose St., MN 226, Lexington, Ky. 40536, e-mail [email protected]. Address correspondence to Dr. Ray. Disclosure. Dr. Ray did not report any disclosures. These summaries, published under the auspices of the American Dental Association Center for Evidence-Based Dentistry, are prepared by practitioners trained in critical appraisal of published systematic reviews who work under the mentorship of experts. The summaries are not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. For more information on the evidence quality rating provided above and additional critical summaries, please visit http://ebd. ada.org. 1. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). Oxford, England: The Cochrane Collaboration; 2011. 2. Samorodnitzky-Naveh GR, Geiger SB, Levin L. Patients’ satisfaction with dental esthetics. JADA 2007;138(6):805-808. 3. Tin-Oo MM, Saddki N, Hassan N. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health 2011;11:6. doi:10.1186/14726831-11-6.

Using light to enhance in-office vital bleaching may increase both efficacy and tooth sensitivity.

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