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ADA Statement on Safety Updates
Peroxide Whitening  
Does Whitening Cause Oral Cancer  


ADA Statement on the Safety and Effectiveness of Tooth Whitening Products

A report last month suggests a "possible" link between tooth whitening and oral cancer. It's based on two case reports of patients who contracted oral cancer with none of the known risk factors. There are no new studies cited.

We call this to your attention because the report got substantial media play. Interestingly, the report itself states that carbamide peroxide and hydrogen peroxide chemicals generated in the whitening process aren't carcinogens in the mouth.


For more than a decade, the ADA Council on Scientific Affairs has monitored the development and the increasing numbers of whitening oral hygiene products. As the market for these products grew, the Association recognized a need for uniform definitions when discussing whiteners.

For example, "whitening" is any process that will make teeth appear whiter. This can be achieved in two ways. A product can bleach the tooth, which means that it actually changes the natural tooth color. Bleaching products contain peroxide(s) that help remove deep (intrinsic) and surface (extrinsic) stains. By contrast, non-bleaching whitening products contain agents that work by physical or chemical action to help remove surface stains only.

Whitening products may be administered or dispensed by dentists or purchased over-the-counter (OTC) and can be categorized into two major groups:

bulletPeroxide-containing whiteners or bleaching agents; and
bulletWhitening toothpastes (dentifrices).

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Peroxide-containing whiteners or bleaching agents

Dentist-dispensed and OTC home-use products
The dentist-dispensed products usually contain 10 percent carbamide peroxide (equivalent to about 3 percent hydrogen peroxide), which is the most commonly used active ingredient in home-use tooth bleaching products. All of the products in this category that bear the ADA Seal of Acceptance contain 10 percent carbamide peroxide; however, participation in the program is not limited to products of this concentration. Although bleaching agents are available OTC, only those dispensed through the dental office are considered for the Seal because professional consultation is important to the procedure's safety and effectiveness.

In a water-based solution, carbamide peroxide breaks down into hydrogen peroxide and urea, with hydrogen peroxide being the active bleaching agent. Other ingredients of peroxide-containing tooth whiteners may include glycerin, carbopol, sodium hydroxide and flavoring agents.

Accumulated clinical data on neutral pH 10 percent carbamide peroxide continue to support both the safety and effectiveness of this kind of tooth-whitening agent. The most commonly observed side effects to hydrogen or carbamide peroxide are tooth sensitivity and occasional irritation of the soft tissues in the mouth (oral mucosa), particularly the gums. Tooth sensitivity often occurs during early stages of bleaching treatment. Tissue irritation, in most cases, results from an ill-fitting tray rather than the tooth-bleaching agents. Both of these conditions usually are temporary and stop after the treatment.

Professionally applied bleach whiteners

There are many professionally applied tooth whitening bleach products. These products use hydrogen peroxide in concentrations ranging from 15 percent to 35 percent and are sometimes used together with a light or laser, which reportedly accelerates the whitening process. Prior to application of professional products, gum tissues are isolated either with a rubber dam or a protective gel. Whereas home-use products are intended for use over a two-to-four week period, the professional procedure is usually completed in about one hour. Currently, all of the professionally applied whiteners that have the ADA Seal contain 35 percent hydrogen peroxide, although this concentration is not a requirement of the program.

As with the 10 percent home-use carbamide peroxide bleach products, the most commonly observed side effects of professionally applied hydrogen peroxide products are temporary tooth sensitivity and occasional irritation of oral tissues. On rare occasions, irreversible tooth damage has been reported.

The ADA advises patients to consult with their dentists to determine the most appropriate treatment. This is especially important for patients with many fillings, crowns, and extremely dark stains. A thorough oral examination, performed by a licensed dentist, is essential to determine if bleaching is an appropriate course of treatment. The dentist then supervises the use of bleaching agents within the context of a comprehensive, appropriately sequenced treatment plan.

Whitening toothpastes
Whitening toothpastes (dentifrices) in the ADA Seal of Acceptance program contain polishing or chemical agents to improve tooth appearance by removing surface stains through gentle polishing, chemical chelation, or some other non-bleaching action. Several whitening toothpastes that are available OTC have received the ADA Seal of Acceptance.

 A recent report suggested a "possible" link between tooth whitening and oral cancer. It was based on two case reports of patients who contracted oral cancer with none of the known risk factors. There are no new studies cited. We call this to your attention because the report got substantial media play. Interestingly, the report itself states that carbamide peroxide and hydrogen peroxide-chemicals generated in the whitening process-aren't carcinogens in the mouth.
June 2002 2003 2004

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Do tooth-whitening products lead to oral cancer? New research suggests that it's certainly possible and a question that's worth further investigation.

Georgetown University Hospital researchers say the active ingredient in these popular whiteners -- available at a dentist's office or in over-the-counter kits -- may be the reason why two patients with no other identifiable risk factors developed advanced tongue cancer while in their 20s.

But when these patients don't have a significant history of this use, you start to wonder what else they are being exposed to," says Bruce Davidson, MD, FACS, chairman of otolaryngology-head and neck surgery at the Washington, D.C., hospital.

Free Radical Damage Suspected

His suspicion: The hydrogen peroxide in the gels dentists apply to whiten teeth and in over-the-counter self-application bleaching kits to whiten teeth. Products are often labeled to contain carbamide peroxide, one-third of which is composed of hydrogen peroxide. In addition, when used as a whitener, carbamide peroxide changes into hydrogen peroxide, say the researchers.

In animal studies, peroxide has been shown to promote the growth of cancerous tumors inside the cheeks of rodents and cause gastrointestinal cancers when ingested. No tests have been done on humans. Specifically, the theory is that when hydrogen peroxide leaks from trays containing the whitening gel onto surrounding areas inside the mouth, it triggers the release of cancer-causing "free radical" cells.

"Further testing is obviously required before we can be certain of a link, but people should be aware there is a possible link," Davidson tells WebMD. "If I was in the market for teeth whitening, I'd think twice about it. I make my career in treating head and neck cancers, so I'm also not going to go out and chew tobacco and smoke cigarettes, either."

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No Additional Risks Noted

Research he presented Saturday at the 6th International Conference on Head and Neck Cancer documents two patients who developed advanced tongue cancer decades earlier than usual, after repeated use of tooth-whitening products. Both patients were occasional drinkers, having no more than three drinks a week. One was a light smoker, the other didn't smoke. They are among 19 oral cancer patients of all ages studied by Davidson's team of head and neck cancer surgeons. A middle-aged man who also developed tongue cancer used tooth-whitening polish, but the other patients didn't use bleaching products. Among six patients who developed oral cancer before age 40, two used tooth whiteners, and both had more advanced cancer than the others, despite not smoking or drinking any more heavily.

The Reaction?

Terry Day, MD, director of head and neck oncologic surgery at Hollings Cancer Center at the Medical University of South Carolina and a spokesman for the American Academy of Otolaryngology-Head and Neck Surgery, says the study deserves notice because it points to why there's a growing trend in young people developing oral cancers -- especially affecting the tongue -- without a long-term history of those damaging vices.

"About 10% to 15% of oral and head and neck cancers do not seem to be related to tobacco and/or alcohol," he tells WebMD. "Other considerations still under investigation include genetic factors, the human papillomavirus (which causes genital warts), and nutrition factors. This study is interesting in that it points to the possibility of another factor being involved. "But due to the small size, it's a serious limitation to whether or not you can say there's a relationship to teeth-whitening agents and oral cancer."

Until now, there has been little research on the long-term effects of tooth whiteners, and Davidson's study is believed to be the first to examine the link between cancer and tooth whiteners. Since they are considered "cosmetic" products, tooth whiteners don't fall under FDA regulation. While dentists have used these gels for some time, commercially available products have only been available for several years, so their long-term effects haven't been studied. American Dental Association spokesman David Sarrett, DMD, a professor of dentistry at Virginia Commonwealth University, says there is no evidence that when used as directed, tooth whiteners increase cancer risk or cause other problems. But he does acknowledge they are abused by some people.

"Some patients are what we call 'tooth-whitening junkies' who are not satisfied until their teeth are snow white, and that's not achievable," he tells WebMD. "Even when using an over-the-counter whitener, I also advise people to first consult with their dentist, and always follow the product directions."

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Leakage a Problem

When whiteners are applied by a dentist, which costs $200 or more, custom-fitted trays are used to hold the gel, reducing risk of hydrogen peroxide leakage; with over-the-counter products, the trays are usually not form-fitting. But even under ideal conditions, reports Davidson, studies show that often less than 50% of the whitener is still in the trays one hour after application, indicating a lot of leakage. Sarrett does caution against buying tooth whitening products over the Internet -- for another reason. "They may have the right ingredients, but because they don't balance ingredients properly, they may not have the right pH, as with gels used by dentists or from reputable companies," he says. "It could be too acidic, which we know can damage tooth enamel."

SOURCES: The 6th International Conference on Head and Neck Cancer, Washington, D.C., Aug. 7-11, 2004. Bruce J. Davidson, MD, FACS, chairman, division of otolaryngology, Georgetown University Hospital, Washington, D.C. Terry Day, MD, director, division of head & neck oncologic surgery, Hollings Cancer Center; associate professor, Medical University of South Carolina, Charleston. David Sarrett, DMD, professor of dentistry and associate vice president of health sciences, Virginia Commonwealth University, Richmond; member, American Dental Association Council on Scientific Affairs.

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Is Teeth Whitening Addictive?

Are you addicted to tooth whitening? raises the question of “whitening addiction,” citing those who have a narcissistic compulsion to maintain their youth by overuse of tooth whitening products, both OTC and professional. Signs of whitening abuse include people who seek to get their teeth to a "Clorox white” shade until their teeth are almost transparent, yet do not seem to realize their teeth are already white. It is unlikely that damage to the surface of the tooth will be caused before the sensitivity occurs. He cautions against bleaching for people under age 18 as there is greater opportunity for hypersensitivity. Dentists need to partner with patients to set realistic expectations and avoid overuse of whitening products.


"Bleachorexis" overwhitening their teeth

ABC news reports that more people are using tooth bleaching – from over the counter products – to dentist prescribed take home kits– to in-office light activated whitening – to pursue a perfectly white smile. As with many cosmetic trends, some “whitening junkies” are aiming for an unnaturally white shade by overusing theproducts. Excessive use of bleaching products can damage tooth structure and gums. Some overly enthusiastic patients experience tooth sensitivity, blisters and discoloration on teeth and gums. 4/05

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Effect of bleaching on  restorations—a systematic review

Existing literature reveals that bleaching therapies may have a negative effect on physical properties, marginal integrity, enamel and dentin bond strength, and color of restorative materials as investigated in numerous in vitro studies. However, there are no reports in literature indicating that bleaching may exert a negative impact on existing restorations requiring renewal of the restorations under clinical conditions.
Attin T, Effect of bleaching on restorative materials and restorations—a systematic review   Dental Materials 2004; 20(9):852-861.]

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