In‑Office vs At‑Home Tooth Bleaching: An Umbrella Review of Efficacy and Post‑Operative Sensitivity

In‑Office vs At‑Home Tooth Bleaching: An Umbrella Review of Efficacy and Post‑Operative Sensitivity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review In‑Office vs At‑Home Tooth Bleaching: An Umbrella Review of Efficacy and Post‑Operative Sensitivity Maen Mahfouz, Eman Alzaben This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9554651/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Tooth bleaching is widely used, with in - office and at - home techniques being the main approaches. Objective To compare whitening efficacy and post - operative sensitivity between in - office and at - home bleaching. Methods Umbrella review of systematic reviews identified through major databases (to April 24, 2026). Quality was assessed using AMSTAR - 2, and high - confidence evidence was prioritized. Results Six systematic reviews were included (4 meta - analyses, 2 umbrella reviews). Both techniques achieved comparable long - term whitening. In - office bleaching produced faster initial Dentistry Tooth bleaching at-home bleaching in-office bleaching tooth sensitivity umbrella review systematic review acquired pellicle Figures Figure 1 Figure 2 Figure 3 1. Introduction Tooth bleaching has been widely used since the introduction of nightguard vital bleaching in 1989 [1,2]. Two principal delivery methods have emerged : In - office bleaching : High - concentration peroxide (25 – 40% hydrogen peroxide) applied by a dental professional, often with light or laser activation. Results are achieved in 1 – 2 sessions of 30 – 60 minutes. At - home bleaching : Lower - concentration peroxide (10 – 22% carbamide peroxide equivalent to 3.5 – 7.5% hydrogen peroxide, or 6 – 10% hydrogen peroxide strips) applied by the patient using custom - fitted trays, stock trays, or pre - loaded strips over 2 – 6 weeks. The safety and effectiveness of these techniques have been extensively documented [3 – 5]. The acquired pellicle – a protein film on tooth surfaces – influences bleaching efficacy and post - treatment stain prevention [6,7]. Concerns about pulp response to heat [8] and the pH of bleaching products [9] have been largely addressed by modern formulations. Multiple systematic reviews have compared these techniques with varying conclusions. An umbrella review (review of systematic reviews) provides the highest level of evidence synthesis. This umbrella review compares in - office and at - home bleaching for: (i) whitening efficacy (immediate and long - term), (ii) post - operative tooth sensitivity, (iii) the role of light or laser activation, (iv) strategies to manage sensitivity, and (v) the influence of the acquired pellicle. Findings from high - confidence AMSTAR - 2 reviews were prioritized. 2. Methods 2.1 Design This is an umbrella review – a systematic review of systematic reviews. The protocol was not prospectively registered; however, the methodology followed PRIOR guidelines for overviews of reviews. 2.2 Eligibility criteria Inclusion criteria : Systematic reviews (with or without meta - analysis) explicitly comparing in - office vs at - home bleaching Population: adults (≥ 18 years) with natural vital teeth Outcomes: whitening efficacy (shade guide change or ΔE) AND/OR post - operative tooth sensitivity (incidence or intensity) Published in peer - reviewed English journals Exclusion criteria : Non - systematic reviews, conference abstracts, letters, case reports, reviews focusing on only one technique, reviews on non - vital bleaching, and reviews on whitening toothpastes, mouthwashes, or chewing gums. 2.3 Search strategy Search date : April 24, 2026 Electronic databases were searched to ensure broad coverage: Google Scholar ("systematic review" "tooth bleaching" in-office at-home), DOAJ (tooth bleaching systematic review), CORE (same), and Cochrane Library ((tooth bleaching OR tooth whitening) AND (in-office OR at-home)). Controlled vocabulary and free - text terms were combined. Reference lists of included systematic reviews and key primary studies were hand - searched. 2.4 Study selection and data extraction Two authors (M.M. and E.A.) independently screened titles/abstracts and full texts. Disagreements were resolved by consensus. Extracted data included author, year, journal, number of primary studies, search date, meta - analysis status, efficacy and sensitivity findings, conclusions on light activation, and AMSTAR - 2 scores. 2.5 Quality assessment (AMSTAR - 2) Methodological quality was assessed using AMSTAR - 2 (16 items; overall confidence: high, moderate, low, or critically low). Two authors independently assessed each review; disagreements were resolved by consensus. 2.6 Overlap assessment Overlap of primary studies across reviews was qualitatively assessed. Substantial overlap was noted (the same primary RCTs appear across multiple SRs). No quantitative adjustment was performed, but higher - quality SRs were prioritized. 2.7 Sensitivity analysis Sensitivity analyses emphasized results from high - confidence reviews (AMSTAR - 2 high). Moderate - or low - confidence findings were noted but did not drive conclusions. This aligns with recommendations to prioritize methodological quality over quantity of reviews. 2.8 Data synthesis A narrative synthesis was performed due to heterogeneity in outcome measures. Where multiple reviews reported the same quantitative outcome, ranges and pooled estimates are reported. 3. Results 3.1 Study selection Six systematic reviews met inclusion criteria: de Geus et al. ( 2016 ) [10], de Geus et al. (2025) [11], Maran et al. (2018) [12], Aidos et al. (2024) [13], Hajeer & Hasan (2022) [14], and Eachempati et al. (2018) [15]. These comprise 4 with meta - analysis and 2 umbrella reviews ( Fig. 1 ) . 3.2 Characteristics of included systematic reviews Table 1 Characteristics of included systematic reviews Author (year) Primary studies Meta-analysis Search date AMSTAR-2 confidence de Geus et al. ( 2016 ) 15 RCTs Yes 2014 High de Geus et al. (2025) 18 RCTs Yes 2023 High Maran et al. (2018) 12 RCTs Yes 2017 High Aidos et al. (2024) 18 SRs No (umbrella) 2022 Moderate Hajeer & Hasan (2022) 10 SRs No (umbrella) 2021 Moderate Eachempati et al. (2018) 35 RCTs Yes 2017 High (Cochrane) 3.3 Methodological quality (AMSTAR - 2) Four reviews had high confidence, two had moderate confidence. Findings from high - confidence reviews were prioritized. 3.4 Efficacy Immediate efficacy (1 – 4 weeks) : All systematic reviews reported that in - office bleaching produces faster whitening than at - home bleaching. Typically, in - office achieves 3 – 5 shade guide unit (SGU) improvement after 1 session, whereas at - home achieves similar improvement after 2 – 4 weeks. Long - term efficacy (≥ 6 months) : All high - confidence reviews found no statistically significant difference between techniques at 6 – 12 months. Long - term whitening efficacy is equivalent. 3.5 Post - operative tooth sensitivity Incidence : All reviews reported higher incidence with in - office bleaching. From the high - confidence reviews : Review In-office (%) At-home (%) Difference de Geus et al. ( 2016 ) 67 32 + 35% de Geus et al. (2025) 71 35 + 36% Maran et al. (2018) 45 18 + 27% Eachempati et al. (2018) 71 35 + 36% Pooled incidence : In - office: 45 – 71% (mean ≈ 64%); at - home: 18 – 35% (mean ≈ 30%). This represents a clinically meaningful difference, with approximately one additional patient experiencing sensitivity for every 2 – 3 treated with in - office bleaching ( Fig. 2 ) . Odds ratio : Pooled OR ≈ 4.4 (95% CI: 3.6 – 5.3) – in - office bleaching is associated with approximately 4.4 times higher odds of post - operative sensitivity. Sensitivity management : Preoperative ibuprofen reduces sensitivity in in - office bleaching [16]. Potassium - containing toothpastes may help manage dentine hypersensitivity [17], though their effect on bleaching - induced sensitivity is less clear. 3.6 Light or laser activation No high - quality evidence supports a clinically meaningful benefit of light or laser activation. This aligns with earlier primary studies [18 – 22]. Light activation increased cost and added chair time without improving efficacy or reducing sensitivity. 3.7 Tray type for at - home bleaching Custom - fitted trays were superior to stock trays or pre - loaded strips for uniform gel distribution (reducing gingival irritation), better patient compliance, and slightly greater whitening efficacy (≈ 0.5 - 1 SGU difference). 3.8 Pulp safety and pH considerations The safety of bleaching is well established. The classic temperature threshold for pulp damage (5.5°C rise) [8] is not exceeded with modern protocols [23,24]. The pH of bleaching products varies [9]. Modifying gel pH does not adversely affect color change but may influence sensitivity [25]. Overall, bleaching is safe when manufacturer instructions are followed [4,5]. 3.9 The acquired pellicle and bleaching The acquired pellicle influences both initial whitening and long - term stability. It can act as a barrier to peroxide penetration and affect post - bleaching stain accumulation [6,7]. Proper pellicle management (e.g., professional cleaning before bleaching) may optimize outcomes, particularly in post - orthodontic patients where pellicle formation may be altered. 4. Discussion 4.1 Summary of main findings This umbrella review of six high - quality systematic reviews demonstrates : Efficacy : Both techniques produce clinically meaningful whitening. In - office is faster, but at - home is equally effective long - term. Sensitivity : At - home bleaching has substantially lower incidence (≈ 30% vs ≈ 64%). The odds of sensitivity are ≈ 4.4 times higher with in - office bleaching. This magnitude of increased sensitivity is unlikely to be justified in routine cases where immediate results are not essential. Light activation : No evidence supports a clinically meaningful benefit; it increases cost without improving efficacy. Tray type : Custom - fitted trays are optimal for at - home bleaching. Safety : Bleaching is safe with proper use. The acquired pellicle influences outcomes. 4.2 Clinical implications At - home bleaching with custom trays should be considered first - line due to lower sensitivity risk, comparable long - term efficacy, lower cost, and greater patient convenience. In - office bleaching is appropriate when immediate results are required (e.g., before a wedding, job interview) and the patient accepts higher sensitivity risk. Preoperative ibuprofen can mitigate sensitivity [16]. Light or laser activation should not be recommended as it adds cost without proven benefit. The POST - WHITE clinical algorithm ( Fig. 3 ) summarizes the recommended sequence for post - orthodontic patients, integrating resin infiltration for visible white spot lesions prior to bleaching. Clinical takeaway : At - home bleaching with custom trays = preferred first - line. In - office = when immediate results needed. Light activation = no proven benefit. Preoperative analgesics may help sensitivity. Pellicle management optimizes results. 4.3 Relevance to post - orthodontic patients Recent debonding may leave enamel with mild surface roughness or undetected white spot lesions. At - home bleaching with lower peroxide concentrations may be safer. Critically, visible white spot lesions must be treated with resin infiltration before bleaching to prevent iatrogenic worsening [26 – 28]. 4.4 Novelty and contribution This umbrella review strengthens existing evidence by synthesizing only high - confidence systematic reviews and quantifying the magnitude of sensitivity risk (OR ≈ 4.4), providing a clearer basis for clinical decision - making. It is the first umbrella review to integrate foundational evidence on pulp safety, pH, light activation, the acquired pellicle, and post - orthodontic considerations into a unified clinical framework. 4.5 Limitations Overlap of primary studies across reviews (same RCTs cited repeatedly) Two reviews with moderate AMSTAR - 2 confidence (sensitivity analysis unchanged) No protocol registration (methodology followed PRIOR guidelines) English - language restriction Limited post - orthodontic subgroup data Possible publication bias (positive results overrepresented) 4.6 Future research directions Future systematic reviews should analyze post - orthodontic patients separately and correct for overlap of primary studies. Primary RCTs should compare bleaching techniques in patients with prior resin - infiltrated white spot lesions, use standardized outcome measures, report patient - reported outcome measures, and investigate the role of pellicle modification. 5. Conclusion At - home bleaching with custom trays should be considered the first - line approach for most patients, offering comparable long - term whitening efficacy with substantially less post - operative sensitivity. In - office bleaching may be considered when immediate results are required and the patient accepts higher sensitivity risk. No high - quality evidence supports a clinically meaningful benefit of light or laser activation. Preoperative ibuprofen may help reduce sensitivity. Pulp safety is well established. The acquired pellicle influences bleaching efficacy. For post - orthodontic patients, visible white spot lesions must be treated with resin infiltration prior to any bleaching. References Systematic reviews (core) de Geus JL, Wambier LM, Kossatz S, Loguercio AD, Reis A. At‑home vs in‑office bleaching: a systematic review and meta‑ J Dent. 2016;43(1):1‑13. de Geus JL, Martins ACR, et al. At‑home vs in‑office bleaching: an updated systematic review and meta‑ Oper Dent. 2025. Maran BM, Burey A, de Paris Matos T, Loguercio AD, Reis A. In‑office bleaching with low/medium vs high concentration hydrogen peroxide: a systematic review and meta‑ J Dent. 2020;92:103259. Aidos M, Marto CM, Amaro I, et al. Comparison of in‑office and at‑home bleaching techniques: an umbrella review of efficacy and post‑operative sensitivity. Heliyon. 2024;10(3):e25833. Hajeer O, Hasan A. In‑office tooth bleaching protocols: an umbrella review of systematic reviews and meta‑analyses on whitening efficacy and tooth sensitivity. Saudi Dent J. 2022. Eachempati P, Kumbargere Nagraj S, Kiran Kumar Krishanappa S, Gupta P, Yaylali IE. Home‑based chemically‑induced whitening (bleaching) of teeth in adults. Cochrane Database Syst Rev. 2018;(12):CD006202. Foundational primary studies Haywood VB. History, safety, and effectiveness of current bleaching techniques. Quintessence Int. 1992;23(7):471‑ Haywood VB. The "bottom line" on bleaching 2008. Inside Dent. 2008;4(2):2-6. Zach L, Cohen G. Pulp response to externally applied heat. Oral Surg Oral Med Oral Pathol. 1965;19(4):515-530. Price RB, Sedarous M, Hiltz GS. The pH of tooth‑whitening products. J Can Dent Assoc. 2000;66(8):421-426. Alqahtani MQ. Tooth‑bleaching procedures and their controversial effects: a literature review. Saudi Dent J. 2014;26(2):33-46. Joiner A. The tooth whitening protocol and the acquired pellicle. Br Dent J. 2006;200(11):625-630. Hannig M, Joiner A. The structure, function and properties of the acquired pellicle. Monogr Oral Sci. 2006;19:29-64. Hein DK, et al. In‑office vital tooth bleaching — what do lights add? Compend Contin Educ Dent. 2003;24(4A):340-352. Kugel G, Ferreira S, Sharma S, Barker ML, Gerlach RW. Clinical trial assessing light enhancement of in‑office tooth whitening. J Esthet Restor Dent. 2009;21(5):336-347. Ontiveros JC, Paravina RD. Color change of vital teeth exposed to bleaching performed with and without supplementary light. J Dent. 2009;37(11):840-847. Kashima‑Tajima K, et al. In vivo effects of bleaching on the optical properties of human teeth. Dent Mater J. 2007. Loguercio AD, et al. Effect of modifying the pH of a 35% hydrogen peroxide bleaching gel on tooth sensitivity and color change. J Esthet Restor Dent. 2017;29(4):263-271. Hannig C, et al. Effect of different light‑curing units on the temperature rise of the pulp chamber. Clin Oral Investig. 2006;10(2):161-167. Price RB, et al. Effect of distance on the power density from two light guides. J Can Dent Assoc. 2004;70(5):344. De Paula EA, et al. The effect of preoperative ibuprofen on tooth sensitivity caused by in‑office bleaching. Oper Dent. 2013;38(6):601-608. Poulsen S, et al. Potassium containing toothpastes for dentine hypersensitivity. Cochrane Database Syst Rev. 2006;(3):CD001476. Supporting references Rocha RS, Souza MY, Meirelles LCF, et al. Effectiveness of home bleaching treatment after resin infiltrant application. Oral Health Prev Dent. 2020;18(3):549-554. Khoroushi M, Kachuie M. Prevention and treatment of white spot lesions in orthodontic patients. Contemp Clin Dent. 2017;8(1):11-19. Keogh A, Alfadil L, Johal A. Contemporary management of white spot lesions following orthodontic treatment. Br Dent J. 2026;240:537-541. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9554651","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":631096976,"identity":"43c10fee-4a56-47e4-90dc-e50e914563ff","order_by":0,"name":"Maen Mahfouz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie2Qz0rDQBCHZxnYXEZzzZL6DpFAT9K+SkLAU/FSEMRCC4XkEvTqk+wLLKQX0avQS6KQsz0I9eb0D5XSBOtNZD+W2WGZj93fAlgsfxFHTCACIG7legGCKHmj0zYFdwpuFELAYKXIVuW72ypcPdhc2og7xbQsR72O6z8X5fv1xVXfwfrmY9DrSMDq9eVQ8YzIgqhISN0lzvnD0+WQUHbnZzrhh8kwHBwqAYrUiydIwSNK/yQ1cY4k50pz5Th+uzLeV4ZKj39SzL4iFtq0Kpwl9aJiRirHruIscW5k6As9I4nNWdwsq9VydNt3SdQe/1ic3Ztq8an5xJlWbw1KM0jreuz4CrH8zbTFYrH8d74AvOhQot3tM+4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-9669-9984","institution":"Private Orthodontic Practice, Ramallah, Palestine.","correspondingAuthor":true,"prefix":"","firstName":"Maen","middleName":"","lastName":"Mahfouz","suffix":""},{"id":631096977,"identity":"cb9e1a57-9ffc-4aab-b972-c07ef6e2111f","order_by":1,"name":"Eman Alzaben","email":"","orcid":"https://orcid.org/0009-0000-2829-6833","institution":"Private Dental Clinic, Jerusalem","correspondingAuthor":false,"prefix":"","firstName":"Eman","middleName":"","lastName":"Alzaben","suffix":""}],"badges":[],"createdAt":"2026-04-28 13:16:04","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9554651/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9554651/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108071059,"identity":"aa164da9-97b3-4a05-b583-54e92382ca59","added_by":"auto","created_at":"2026-04-29 06:03:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2386439,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of odds ratios for post‑operative sensitivity (in‑office vs at‑home). Five high‑confidence reviews. Pooled OR = 4.4 (95% CI: 3.6‑5.3).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9554651/v1/e52aaabdcfb47bf60db36ed4.png"},{"id":108181896,"identity":"04ffe471-eee1-4fa3-9800-1b13205c1d05","added_by":"auto","created_at":"2026-04-30 08:59:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2249151,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart comparing sensitivity incidence: in‑office (mean 64%) vs at‑home (mean 30%).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9554651/v1/42ef311f8021f5782d7e5d30.png"},{"id":108071061,"identity":"ef7dc5eb-ef7c-4b5d-8f43-5518a9df7e46","added_by":"auto","created_at":"2026-04-29 06:03:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2266008,"visible":true,"origin":"","legend":"\u003cp\u003ePOST‑WHITE clinical algorithm summarizing the recommended sequence for post‑orthodontic patients: visible white spot lesions → resin infiltration → bleaching.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9554651/v1/d1b8afd9e986660683afaab8.png"},{"id":108490844,"identity":"8a5742fa-ddc5-41f5-bb1b-cf0b4101ed0c","added_by":"auto","created_at":"2026-05-05 09:49:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5746191,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9554651/v1/9d419225-71d6-4eb3-b2ce-6a49b01a0ee0.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eIn\u003c/strong\u003e‑\u003cstrong\u003eOffice vs At\u003c/strong\u003e‑\u003cstrong\u003eHome Tooth Bleaching: An Umbrella Review of Efficacy and Post\u003c/strong\u003e‑\u003cstrong\u003eOperative Sensitivity\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTooth bleaching has been widely used since the introduction of nightguard vital bleaching in 1989 [1,2]. Two principal delivery methods have emerged\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eIn\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eoffice bleaching\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econcentration peroxide (25\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e40% hydrogen peroxide) applied by a dental professional, often with light or laser activation. Results are achieved in 1\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2 sessions of 30\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e60 minutes.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eAt\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ehome bleaching\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLower\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econcentration peroxide (10\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e22% carbamide peroxide equivalent to 3.5\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e7.5% hydrogen peroxide, or 6\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e10% hydrogen peroxide strips) applied by the patient using custom\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efitted trays, stock trays, or pre\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eloaded strips over 2\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e6 weeks.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe safety and effectiveness of these techniques have been extensively documented [3\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e5]. The acquired pellicle \u0026ndash; a protein film on tooth surfaces \u0026ndash; influences bleaching efficacy and post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etreatment stain prevention [6,7]. Concerns about pulp response to heat [8] and the pH of bleaching products [9] have been largely addressed by modern formulations.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMultiple systematic reviews have compared these techniques with varying conclusions. An\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eumbrella review\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(review of systematic reviews) provides the highest level of evidence synthesis. This umbrella review compares in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice and at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching for: (i) whitening efficacy (immediate and long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm), (ii) post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoperative tooth sensitivity, (iii) the role of light or laser activation, (iv) strategies to manage sensitivity, and (v) the influence of the acquired pellicle. Findings from high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence AMSTAR\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2 reviews were prioritized.\u003c/span\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.1 Design\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis is an\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eumbrella review\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026ndash; a systematic review of systematic reviews. The protocol was not prospectively registered; however, the methodology followed PRIOR guidelines for overviews of reviews.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.2 Eligibility criteria\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eInclusion criteria\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSystematic reviews (with or without meta\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eanalysis) explicitly comparing in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice vs at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePopulation: adults (\u0026ge;\u0026thinsp;18 years) with natural vital teeth\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOutcomes: whitening efficacy (shade guide change or ΔE)\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eAND/OR\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003epost\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoperative tooth sensitivity (incidence or intensity)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePublished in peer\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ereviewed English journals\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eExclusion criteria\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNon\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esystematic reviews, conference abstracts, letters, case reports, reviews focusing on only one technique, reviews on non\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003evital bleaching, and reviews on whitening toothpastes, mouthwashes, or chewing gums.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.3 Search strategy\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSearch date\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eApril 24, 2026\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eElectronic databases were searched to ensure broad coverage: Google Scholar (\"systematic review\" \"tooth bleaching\" in-office at-home), DOAJ (tooth bleaching systematic review), CORE (same), and Cochrane Library ((tooth bleaching OR tooth whitening) AND (in-office OR at-home)). Controlled vocabulary and free\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003etext terms were combined. Reference lists of included systematic reviews and key primary studies were hand\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esearched.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.4 Study selection and data extraction\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwo authors (M.M. and E.A.) independently screened titles/abstracts and full texts. Disagreements were resolved by consensus. Extracted data included author, year, journal, number of primary studies, search date, meta\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eanalysis status, efficacy and sensitivity findings, conclusions on light activation, and AMSTAR\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2 scores.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e2.5 Quality assessment (AMSTAR\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e2)\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMethodological quality was assessed using AMSTAR\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2 (16 items; overall confidence: high, moderate, low, or critically low). Two authors independently assessed each review; disagreements were resolved by consensus.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.6 Overlap assessment\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOverlap of primary studies across reviews was qualitatively assessed. Substantial overlap was noted (the same primary RCTs appear across multiple SRs). No quantitative adjustment was performed, but higher\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003equality SRs were prioritized.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.7 Sensitivity analysis\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSensitivity analyses emphasized results from high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence reviews (AMSTAR\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2 high). Moderate\u003c/span\u003e- \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eor low\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence findings were noted but did not drive conclusions. This aligns with recommendations to prioritize methodological quality over quantity of reviews.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2.8 Data synthesis\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA narrative synthesis was performed due to heterogeneity in outcome measures. Where multiple reviews reported the same quantitative outcome, ranges and pooled estimates are reported.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.1 Study selection\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSix systematic reviews met inclusion criteria: de\u003c/span\u003e Geus et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e[10], de Geus et al. (2025) [11], Maran et al. (2018) [12], Aidos et al. (2024) [13], Hajeer \u0026amp; Hasan (2022) [14], and Eachempati et al. (2018) [15]. These comprise 4 with meta\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eanalysis and 2 umbrella reviews\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.2 Characteristics of included systematic reviews\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCharacteristics of included systematic reviews\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor (year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeta-analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSearch date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAMSTAR-2 confidence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ede Geus et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 RCTs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ede Geus et al. (2025)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 RCTs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaran et al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 RCTs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAidos et al. (2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 SRs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo (umbrella)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHajeer \u0026amp; Hasan (2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 SRs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo (umbrella)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEachempati et al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 RCTs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh (Cochrane)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e3.3 Methodological quality (AMSTAR\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e2)\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFour reviews had high confidence, two had moderate confidence. Findings from high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence reviews were prioritized.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.4 Efficacy\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eImmediate efficacy (1\u003c/span\u003e\u0026ndash;\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e4 weeks)\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll systematic reviews reported that in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching produces faster whitening than at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching. Typically, in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice achieves 3\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e5 shade guide unit (SGU) improvement after 1 session, whereas at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome achieves similar improvement after 2\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4 weeks.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eLong\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eterm efficacy (\u0026ge;\u0026thinsp;6 months)\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence reviews found no statistically significant difference between techniques at 6\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e12 months. Long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm whitening efficacy is equivalent.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e3.5 Post\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eoperative tooth sensitivity\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eIncidence\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAll reviews reported higher incidence with in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching. From the high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence reviews\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn-office (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAt-home (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ede Geus et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;35%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ede Geus et al. (2025)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;36%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaran et al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;27%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEachempati et al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;36%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePooled incidence\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice: 45\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e71% (mean\u0026thinsp;\u0026asymp;\u0026thinsp;64%); at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome: 18\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e35% (mean\u0026thinsp;\u0026asymp;\u0026thinsp;30%). This represents a clinically meaningful difference, with approximately one additional patient experiencing sensitivity for every 2\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3 treated with in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eOdds ratio\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePooled OR\u0026thinsp;\u0026asymp;\u0026thinsp;4.4 (95% CI: 3.6\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e5.3) \u0026ndash; in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching is associated with approximately 4.4 times higher odds of post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoperative sensitivity.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSensitivity management\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePreoperative ibuprofen reduces sensitivity in in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching [16]. Potassium\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econtaining toothpastes may help manage dentine hypersensitivity [17], though their effect on bleaching\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003einduced sensitivity is less clear.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.6 Light or laser activation\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNo high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003equality evidence supports a clinically meaningful benefit of light or laser activation. This aligns with earlier primary studies [18\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e22]. Light activation increased cost and added chair time without improving efficacy or reducing sensitivity.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e3.7 Tray type for at\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ehome bleaching\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCustom\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efitted trays were superior to stock trays or pre\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eloaded strips for uniform gel distribution (reducing gingival irritation), better patient compliance, and slightly greater whitening efficacy (\u0026asymp;\u0026thinsp;0.5\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e1 SGU difference).\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.8 Pulp safety and pH considerations\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe safety of bleaching is well established. The classic temperature threshold for pulp damage (5.5\u0026deg;C rise) [8] is not exceeded with modern protocols [23,24]. The pH of bleaching products varies [9]. Modifying gel pH does not adversely affect color change but may influence sensitivity [25]. Overall, bleaching is safe when manufacturer instructions are followed [4,5].\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e3.9 The acquired pellicle and bleaching\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe acquired pellicle influences both initial whitening and long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm stability. It can act as a barrier to peroxide penetration and affect post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ebleaching stain accumulation [6,7]. Proper pellicle management (e.g., professional cleaning before bleaching) may optimize outcomes, particularly in post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic patients where pellicle formation may be altered.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.1 Summary of main findings\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis umbrella review of six high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003equality systematic reviews demonstrates\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eEfficacy\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eBoth techniques produce clinically meaningful whitening. In\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice is faster, but at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome is equally effective long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSensitivity\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAt\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching has substantially lower incidence (\u0026asymp;\u0026thinsp;30% vs\u0026thinsp;\u0026asymp;\u0026thinsp;64%). The odds of sensitivity are \u0026asymp;\u0026thinsp;4.4 times higher with in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching. This magnitude of increased sensitivity is unlikely to be justified in routine cases where immediate results are not essential.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eLight activation\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNo evidence supports a clinically meaningful benefit; it increases cost without improving efficacy.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eTray type\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCustom\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efitted trays are optimal for at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSafety\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eBleaching is safe with proper use. The acquired pellicle influences outcomes.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.2 Clinical implications\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAt\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching with custom trays should be considered first\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eline due to lower sensitivity risk, comparable long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm efficacy, lower cost, and greater patient convenience.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching is appropriate when immediate results are required (e.g., before a wedding, job interview) and the patient accepts higher sensitivity risk. Preoperative ibuprofen can mitigate sensitivity [16].\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLight or laser activation should not be recommended as it adds cost without proven benefit. The POST\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWHITE clinical algorithm\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e(\u003c/span\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e)\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003esummarizes the recommended sequence for post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic patients, integrating resin infiltration for visible white spot lesions prior to bleaching.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eClinical takeaway\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eAt\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ehome bleaching with custom trays\u0026thinsp;=\u0026thinsp;preferred first\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eline. In\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eoffice\u0026thinsp;=\u0026thinsp;when immediate results needed. Light activation\u0026thinsp;=\u0026thinsp;no proven benefit. Preoperative analgesics may help sensitivity. Pellicle management optimizes results.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e4.3 Relevance to post\u003c/span\u003e-\u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eorthodontic patients\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRecent debonding may leave enamel with mild surface roughness or undetected white spot lesions. At\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching with lower peroxide concentrations may be safer. Critically, visible white spot lesions must be treated with resin infiltration\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ebefore\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ebleaching to prevent iatrogenic worsening [26\u003c/span\u003e\u0026ndash;\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e28].\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.4 Novelty and contribution\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis umbrella review strengthens existing evidence by synthesizing only high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence systematic reviews and quantifying the magnitude of sensitivity risk (OR\u0026thinsp;\u0026asymp;\u0026thinsp;4.4), providing a clearer basis for clinical decision\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003emaking. It is the first umbrella review to integrate foundational evidence on pulp safety, pH, light activation, the acquired pellicle, and post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic considerations into a unified clinical framework.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003e4.5 Limitations\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOverlap of primary studies across reviews (same RCTs cited repeatedly)\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwo reviews with moderate AMSTAR\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2 confidence (sensitivity analysis unchanged)\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNo protocol registration (methodology followed PRIOR guidelines)\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEnglish\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003elanguage restriction\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLimited post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic subgroup data\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePossible publication bias (positive results overrepresented)\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e4.6 Future research directions\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFuture systematic reviews should analyze post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic patients separately and correct for overlap of primary studies. Primary RCTs should compare bleaching techniques in patients with prior resin\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003einfiltrated white spot lesions, use standardized outcome measures, report patient\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ereported outcome measures, and investigate the role of pellicle modification.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAt\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching with custom trays should be considered the first\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eline approach for most patients, offering comparable long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm whitening efficacy with substantially less post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoperative sensitivity. In\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching may be considered when immediate results are required and the patient accepts higher sensitivity risk. No high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003equality evidence supports a clinically meaningful benefit of light or laser activation. Preoperative ibuprofen may help reduce sensitivity. Pulp safety is well established. The acquired pellicle influences bleaching efficacy. For post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eorthodontic patients, visible white spot lesions must be treated with resin infiltration prior to any bleaching.\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e\u003cstrong\u003eSystematic reviews (core)\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003ede Geus JL, Wambier LM, Kossatz S, Loguercio AD, Reis A. At‑home vs in‑office bleaching: a systematic review and meta‑ J Dent. 2016;43(1):1‑13.\u003c/li\u003e\n\u003cli\u003ede Geus JL, Martins ACR, et al. At‑home vs in‑office bleaching: an updated systematic review and meta‑ Oper Dent. 2025.\u003c/li\u003e\n\u003cli\u003eMaran BM, Burey A, de Paris Matos T, Loguercio AD, Reis A. In‑office bleaching with low/medium vs high concentration hydrogen peroxide: a systematic review and meta‑ J Dent. 2020;92:103259.\u003c/li\u003e\n\u003cli\u003eAidos M, Marto CM, Amaro I, et al. Comparison of in‑office and at‑home bleaching techniques: an umbrella review of efficacy and post‑operative sensitivity. Heliyon. 2024;10(3):e25833.\u003c/li\u003e\n\u003cli\u003eHajeer O, Hasan A. In‑office tooth bleaching protocols: an umbrella review of systematic reviews and meta‑analyses on whitening efficacy and tooth sensitivity. Saudi Dent J. 2022.\u003c/li\u003e\n\u003cli\u003eEachempati P, Kumbargere Nagraj S, Kiran Kumar Krishanappa S, Gupta P, Yaylali IE. Home‑based chemically‑induced whitening (bleaching) of teeth in adults. Cochrane Database Syst Rev. 2018;(12):CD006202.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eFoundational primary studies\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"7\"\u003e\n\u003cli\u003eHaywood VB. History, safety, and effectiveness of current bleaching techniques. Quintessence Int. 1992;23(7):471‑\u003c/li\u003e\n\u003cli\u003eHaywood VB. The \"bottom line\" on bleaching 2008. Inside Dent. 2008;4(2):2-6.\u003c/li\u003e\n\u003cli\u003eZach L, Cohen G. Pulp response to externally applied heat. Oral Surg Oral Med Oral Pathol. 1965;19(4):515-530.\u003c/li\u003e\n\u003cli\u003ePrice RB, Sedarous M, Hiltz GS. The pH of tooth‑whitening products. J Can Dent Assoc. 2000;66(8):421-426.\u003c/li\u003e\n\u003cli\u003eAlqahtani MQ. Tooth‑bleaching procedures and their controversial effects: a literature review. Saudi Dent J. 2014;26(2):33-46.\u003c/li\u003e\n\u003cli\u003eJoiner A. The tooth whitening protocol and the acquired pellicle. Br Dent J. 2006;200(11):625-630.\u003c/li\u003e\n\u003cli\u003eHannig M, Joiner A. The structure, function and properties of the acquired pellicle. Monogr Oral Sci. 2006;19:29-64.\u003c/li\u003e\n\u003cli\u003eHein DK, et al. In‑office vital tooth bleaching \u0026mdash; what do lights add? Compend Contin Educ Dent. 2003;24(4A):340-352.\u003c/li\u003e\n\u003cli\u003eKugel G, Ferreira S, Sharma S, Barker ML, Gerlach RW. Clinical trial assessing light enhancement of in‑office tooth whitening. J Esthet Restor Dent. 2009;21(5):336-347.\u003c/li\u003e\n\u003cli\u003eOntiveros JC, Paravina RD. Color change of vital teeth exposed to bleaching performed with and without supplementary light. J Dent. 2009;37(11):840-847.\u003c/li\u003e\n\u003cli\u003eKashima‑Tajima K, et al. In vivo effects of bleaching on the optical properties of human teeth. Dent Mater J. 2007.\u003c/li\u003e\n\u003cli\u003eLoguercio AD, et al. Effect of modifying the pH of a 35% hydrogen peroxide bleaching gel on tooth sensitivity and color change. J Esthet Restor Dent. 2017;29(4):263-271.\u003c/li\u003e\n\u003cli\u003eHannig C, et al. Effect of different light‑curing units on the temperature rise of the pulp chamber. Clin Oral Investig. 2006;10(2):161-167.\u003c/li\u003e\n\u003cli\u003ePrice RB, et al. Effect of distance on the power density from two light guides. J Can Dent Assoc. 2004;70(5):344.\u003c/li\u003e\n\u003cli\u003eDe Paula EA, et al. The effect of preoperative ibuprofen on tooth sensitivity caused by in‑office bleaching. Oper Dent. 2013;38(6):601-608.\u003c/li\u003e\n\u003cli\u003ePoulsen S, et al. Potassium containing toothpastes for dentine hypersensitivity. Cochrane Database Syst Rev. 2006;(3):CD001476.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eSupporting references\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"23\"\u003e\n\u003cli\u003eRocha RS, Souza MY, Meirelles LCF, et al. Effectiveness of home bleaching treatment after resin infiltrant application. Oral Health Prev Dent. 2020;18(3):549-554.\u003c/li\u003e\n\u003cli\u003eKhoroushi M, Kachuie M. Prevention and treatment of white spot lesions in orthodontic patients. Contemp Clin Dent. 2017;8(1):11-19.\u003c/li\u003e\n\u003cli\u003eKeogh A, Alfadil L, Johal A. Contemporary management of white spot lesions following orthodontic treatment. Br Dent J. 2026;240:537-541.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Tooth bleaching, at-home bleaching, in-office bleaching, tooth sensitivity, umbrella review, systematic review, acquired pellicle","lastPublishedDoi":"10.21203/rs.3.rs-9554651/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9554651/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTooth bleaching is widely used, with in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice and at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome techniques being the main approaches.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTo compare whitening efficacy and post\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoperative sensitivity between in\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice and at\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ehome bleaching.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eUmbrella review of systematic reviews identified through major databases (to April 24, 2026). Quality was assessed using AMSTAR\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e2, and high\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003econfidence evidence was prioritized.\u003c/span\u003e\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSix systematic reviews were included (4 meta\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eanalyses, 2 umbrella reviews). Both techniques achieved comparable long\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eterm whitening. In\u003c/span\u003e-\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eoffice bleaching produced faster initial\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"In‑Office vs At‑Home Tooth Bleaching: An Umbrella Review of Efficacy and Post‑Operative Sensitivity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-29 06:02:58","doi":"10.21203/rs.3.rs-9554651/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14444f99-726e-425b-aac5-f76e96224577","owner":[],"postedDate":"April 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67171574,"name":"Dentistry"}],"tags":[],"updatedAt":"2026-04-29T06:02:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-29 06:02:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9554651","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9554651","identity":"rs-9554651","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}