Review Article

Effect of Bleaching Agents on Discoloured Resin‑Based Composites for

Direct Restorations: A Systematic Review
Khaled Abid Althaqafi1, Abdulrahman Alshabib2

1
Department of Restorative The purpose of the review was to assess the influence of office and home

Abstract
Dentistry, Faculty of
Dentistry, College of Dental
bleaching on the color durability after staining of resin‑based composites (RCs)
Medicine, University of for direct restorations. A web‑based search for possibly relevant scientific papers
Umm Al Qura, Makkah, in the English language between January 2013 and August 2022 was conducted in
Saudi Arabia, 2Department the databases such as PubMed, Scopus, Cochrane Library, and EMBASE. In‑vitro
of Restorative Dentistry, studies that explored the influence of in‑office and other bleaching treatments on
Faculty of Dentistry, the discolored RC for direct restorations in extracted human teeth were included.
College of Dentistry, King
Saud University, Riyadh,
Case studies, case series, animal studies, systematic reviews, and letters to the
Saudi Arabia editor were not considered. A total of 212 articles from a web‑based search and 32
studies from a manual search were retrieved. After removal of duplicate records,
181 titles and abstracts were reviewed for eligibility; 92 were chosen for full‑text
analysis, and nine in‑vitro studies matched the inclusion criteria. The two examiners
examined the methodological quality of the selected studies independently based
on the study design, methodological soundness, and data analysis. Distinct values
were assigned to studies evaluating color variations of stained RC subjected
to bleaching agents. The methodological quality scores were expressed as a
percentage of the highest possible score based on the established scoring system
and categorized as indicating a low, moderate, and high level of evidence. The
reversal of color alterations following home and office bleaching was found to be
dependent on the RC used. Within the limitations of the in‑vitro investigations, it
was deduced that the bleaching agents were successful in eliminating stains and
Submitted: 28-Oct-2022
improving the durability of the color to near baseline values.
Revised: 14-Dec-2022
Accepted: 18-Dec-2022
Keywords: Coffee, color stability, composite resins, direct restorations, hydrogen
Published: 05-Jul-2023 peroxide, red wine

Introduction Spectrophotometers and colorimeters have been widely

utilized in assessing discoloration because they reduce
O ne of the most essential characteristics of aesthetic
dental restorations in the context of treatment
endurance is the durability of the color of the resin‑based
subjective inaccuracies.[6] The color of the specimen
is frequently examined using a computerized image
composites (RC) being used for direct restorations.[1] The analytical method in the Commission International de
propensity of the discoloration might be related to the I’Eclairege L*a*b* (CIELab) color system.[7,8] The
type of filler or its matrix.[2] Under oral conditions, the color differences (ΔE) value depicts the relative color
aesthetic restorations may be subjected to the cumulative changes of tooth surfaces or dental materials prior to and
effects of moisture, tobacco, and caffeine use which may
result in extrinsic discoloration.[3] The susceptibility of Address for correspondence: Dr. Khaled Abid Althaqafi,
Department of Restorative Dentistry, Faculty of Dentistry, College
the resin for exogenous discoloration is regulated by of Dental Medicine, University of Umm Al Qura, Makkah ‑24211,
its rate of conversion, water sorption rate, physical, and Saudi Arabia.
chemical properties.[4,5] E‑mail: kgthaqafi@[Link]

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How to cite this article: Althaqafi KA, Alshabib A. Effect of bleaching

DOI: 10.4103/jpbs.jpbs_528_22 agents on discoloured resin‑based composites for direct restorations:
A systematic review. J Pharm Bioall Sci 2023;15:S1-10.

© 2023 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow S1
 Althaqafi and Alshabib: Discoloration of composite resins

following any intervention. According to the literature, Search strategy

ΔE less than one are not perceptible to the human eye. A web‑based search for possibly relevant scientific
Values of ΔE ranging from 1 to 3.3 are deemed noticeable papers in the English language between January 2013
by experts but clinically satisfactory, whereas ΔE greater and August 2022 was undertaken in the databases
than 3.3 is recognized by non‑skilled individuals but such as PubMed, Scopus, Cochrane Library, and
clinically not acceptable. The CIELab system evaluates EMBASE through the EBSCO host. The following
chromatic value in three coordinates: “L” indicates the Medical Subject Headings (MeSH) phrases were
lightness estimated from zero (black) to 100 (white); the employed: (“Oral Bleaching agents” OR “Hydrogen
value of “a” less than zero represents color in the red, peroxide” OR “In‑office Bleach” OR “Bleaching
and “a” greater than zero indicates green axes, and value Application” OR “Bleaching Agents” OR “Carbamide
of “b” less than zero depicts the color in the blue, and peroxide” OR “Home Bleach”) AND (“Colour
“b” greater than zero represents yellow axes.[1,4,9] Change” OR “Colour Stability” OR “Color Stability”
Tea, coffee, fruit juices, red wine, and carbonated OR “Staining”) AND (“Resin‑Based Composites” OR
beverages have been documented to induce substantial “Composite Resins” OR “Direct Restorative Materials”)
discoloration in RC.[10] Red wine, a widely consumed AND (“Stained Composite Resins” OR “Resin‑based
beverage around the world, is known to cause a clinically Composites”).
unacceptable color variance by applying CIEDE 2000 Study selection
color analytical system (∆E00). Color difference of ∆E00 The initial screening of the titles and abstracts was
greater than 1.79 for several RC was observed after conducted independently by two reviewers. Following
staining with red wine.[11] Peroxide‑derived bleaching the initial screening, studies that fulfilled the eligibility
products serve as a powerful oxidizing agent, generating criteria were subjected to a full‑text examination.
free radicals, thereby dividing chromophore complexes Additionally, the references of the articles chosen were
into small particles and thus enhancing teeth whitening. explored for retrieving further articles. Their eligibility
The most popular teeth whitening techniques are for the review was validated following interaction with
at‑home and in‑office bleaching employing varying a third reviewer in the event of discrepancies among the
concentrations of carbamide peroxide (CP) and hydrogen reviewers.
peroxide (HP), respectively. The longer exposure period
Quality assessment of the included studies
and higher concentration of the bleaching agents enable
better oxidation of complex molecules derived from the The two examiners examined the methodological
staining pigments.[12‑14] quality of the selected studies independently based
on the study design, methodological soundness, and
The possible outcome of bleaching agents on RC data analysis available. Table 1 shows the established
appears to be dependent on the type of concentration of scoring systems.[17‑19] Distinct values were assigned to
the bleaching agents and the restorative materials under studies evaluating color variations of stained RC for
investigation. Nevertheless, the literature on the effects direct restorations subjected to bleaching agents. The
of bleaching agents on various RC is inconclusive.[15] methodological quality scores were expressed as a
The purpose of the review was to assess the influence of percentage of the highest possible score (24 points) as
in‑office and at‑home bleaching on the color durability follows: A mean score of less than 60% indicates a low
after staining of RC for direct restorations. level of evidence. The study is said to have a moderate
level of evidence when a mean score of 60%–70% is
Materials and Methods obtained. A mean score of more than 70% represents a
The systematic review complied with the Preferred high level of evidence.
Reporting Items for Systematic Reviews and
The Commission Internationale de l’Eclairage color
Meta‑Analyses (PRISMA).[16] Following the
system has been established as a realistic approach
population, intervention, comparator, outcome, and
for quantifying and comparing the color of a specific
study design (PICOS) criteria, a targeted question was
element to reference standards. Various parameters
formulated for the review.
have been observed to influence the polymerization
Structured question rate of RC, which include the power density of the
Are there any differences in the bleaching effects of light‑polymerizing unit and the duration of curing used
in‑office (I) and other bleaching agents (C) of various for photoactivation of the specimens. These variables
concentrations on color durability (O) of stained RC were taken into account because it has been directly
for direct restorations in in‑vitro studies (S) of human connected to the mechanical properties of the material.
extracted teeth (P)? In addition, the staining solutions, the temperature of the

S2 Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023

 Althaqafi and Alshabib: Discoloration of composite resins

Table 1: Methodological assessment of evaluated criteria the type of RC.[17,19] Hence in terms of evaluation of the
in the studies included study methodology, the mechanical properties of the RC,
Evaluated criteria Description Maximum the light‑curing protocol, the time, and irradiance of the
score (24) light‑curing unit were assessed. In terms of soundness of
Study design the data analysis, appropriateness of the statistical tests
Objectives/purpose If clearly formulated: 1 point 1 applied, statement of the P value, and other measures of
of the study variances such as range, confidence interval, or standard
Sample size (n n >10: 3 points 3
deviation, were also taken into account which was
per experimental/ n between 5 to 10: 2 points
control groups) in congruence with the established scoring system.[18]
<5: 1 point
Table 1 represents detailed descriptions of the evidence
Randomization If properly stated: 1 point 1
level of all the included studies.
Experimental/ Comparison of two or more 6
control groups staining media: 2 points Data extraction
Use of one staining media: 1 The two reviewers (KA and AA) compiled the data
point on the pre‑defined variables of concern for eventual
Comparison of two or more inferences. From each of the included studies,
resin based composite (RBC)
information on the author‑year of publication, sample
materials: 2 points
size, RC used, polymerization technique, staining media,
Use of one RBC material: 1
points
immersion time, bleaching agents, and evaluation of
color durability were gathered. The color durability of
Comparison of two or more
bleaching agents: 2 points stained composites following bleaching was the outcome
No comparison with other
variable of the current systematic review. Any pertinent
bleaching agents: 1 point difficulties were handled through consensus, with the
Soundness of involvement of a third examiner. The methodological
methodology concerns were resolved by approaching the appropriate
Type of the Nanohybrid composites: 2 points 2 authors.
composites used Other composites: 1 point
Protocol of Clearly describes time, power 3 Results
polymerization density, and light A total of 244 items were found (212 studies from
polymerization protocol: 1 point web‑based search and 32 from manual search), with
each
63 being duplicate records. As a result, the titles and
Immersion time Clearly describes time, 3
temperature, and storage media:
abstracts of 181 studies were reviewed for eligibility;
1 point each 92 articles were chosen for full‑text analysis, and
Colour Spectrophotometer with CIELab 2 nine in‑vitro studies[10,15,20‑26] matched the inclusion
quantification system: 2 points criteria [Figure 1]. In‑vivo studies were not deemed
method Visual method: 1 point relevant based on the eligibility criteria since they did
Data analysis not disclose the parameters required to be included.
Statistical analysis Appropriate statistical tests 1 Table 2 summarizes the salient characteristics of the
applied: 1 point included studies. Table 3 illustrates detailed information
Data presentation If P value stated: 1 point 2 on the RC used and the polymerization strategy of the
Other variability measures selected studies in the review.
stated (standard deviation,
confidence interval, or range): Most investigations employed 2‑mm‑thick specimens,
1 point and the sample size ranged from 36 to 108 specimens.
After polymerization of the resins, while all the
media, and the duration of the immersion media were included investigations utilized two or more staining
also examined. solutions, coffee was the sole staining medium used
by Araújo et al.[21] Four of the included studies[10,21,23,26]
In the context of study design assessment, statement of compared stability of the color after staining and
randomization, sample size, formulation of the objective bleaching using multiple resin materials. Filtek Z350
of the study, control/test groups addressing resin XT was evaluated in four studies[15,20,21,26] followed by
materials, staining media, and bleaching agents were Filtek Z550 XT[23,25] in two studies and Filtek Z250
reviewed. It has been documented that there exists a XT[23] in one study [Table 3]. While Sunildath et al.[24]
strong association between the light‑curing strategy and evaluated the bleaching effect followed by staining of

Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023 S3

 Althaqafi and Alshabib: Discoloration of composite resins

continually in the relevant staining solutions for 48 hours

at 37°C, after which the specimens were completely
cleaned with distilled water and maintained at 37°C in
relative humidity for 24 hours before bleaching. The
resins were soaked periodically for 30 days in the other
two studies.[10,23]
The HP concentrations employed in the studies ranged
from 6% to 40%. In eight studies, CP concentrations
varying from 10% to 22% were employed. Zhao et al.[22]
compared a commercialized at‑home tooth whitening gel
containing 6% HP for 30 minutes/day for 8 days to that
of a 35% HP in‑office bleach for 30 minutes/session for
a total of two appointments. Sunildath et al.[24] and Gul
et al.[25] utilized Crest 3D whitening dental paste and
mouthwash, respectively. Araújo et al.[21] investigated
the use of three sessions of 35% HP, an in‑office bleach
for 15 minutes on the 7th, 14th, and 21st day, and 22%
CP, an at‑home‑bleach for one hour for 14 days. The
differences in color assessments were then acquired
over the baseline period, 7th, 14th, and 21st days.
Spectrophotometers were the most widely utilized color
evaluation devices in all the studies reviewed. Colour
differences were measured using the CIELab system in
five studies[21‑24,26] and the CIEDE 2000 system in four of
the studies.[10,15,20,25]
The quality assessment scores of the study design
Figure 1: PRISMA flowchart of the included studies (Adapted from ranged from 73% to 100%, with an average score of
preferred Reporting Items for systematic reviews and Meta‑analyses 89% corresponding to a high evidence level. In terms of
2009 flow diagram)
methodological quality, the assessment score varied from
50% to 100%, with an average score of 81% indicating
GC Solare Sculpt, a nanohybrid RC, Zhao et al.[22] a high level of evidence. Similarly, the methodological
utilized Filtek Supreme Ultra, a nanofilled universal RC. quality of data analysis of all the selected studies
Erturk‑Avunduk et al.[10] evaluated color change in nine was also assigned a high evidence level (100%). The
bulk‑fill and one nanohybrid RC stained with red wine, cumulative quality assessment scores varied from 75%
coffee, and tea which were later subjected to bleaching to 100%, with an average score of 88% suggesting a
with HP and CP. Araújo et al.[21] also used bulk‑fill high level of evidence [Table 4]. As the methodology of
composites. In four studies, the color shade of RC was the selected studies was so varied, no meta‑analysis was
specifically mentioned.[15,22,25,26] performed.
With the exception of Lago et al.,[15] coffee was the most
commonly employed staining media in all the studies Discussion
reviewed, followed by red wine,[10,15,20,22] tea,[10,26] and The review indicates that the bleaching procedures caused
turmeric.[24] Hasani et al.[23] utilized chlorhexidine as satisfactory color changes in RC. Spectrophotometers
the staining medium. While Zhao et al.[22] employed were employed in all the selected investigations for
soy sauce, Gul et al.[25] and Mota et al.[20] used turnip standardized and consistent measurement of changes
juice and simulated saliva, respectively. In four studies, in color. According to recent studies, the CIEDE 2000
distilled water was employed as the control medium. color variation formula provides a superior congruency
Zhao et al.[22] administered 56 minutes of cigarette smoke by including explicit non‑uniformity corrections in the
and 75 minutes of electronic cigarette vapor besides soy CIELab color analysis system.[10,20,25]
sauce, red wine, and coffee solution for 56 minutes/day The surface roughness and susceptibility to extrinsic
for 15 days at 22 ± 1°C. The techniques for immersing discoloration are directly affected by the particulate
the RC in the staining medium differed greatly between characteristics of the RC. Discoloration of RC can
the in‑vitro studies. Mota et al.[20] immersed the RC be caused by both internal and external factors.[27,28] It

S4 Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023

 Table 2: Summary characteristics of the included studies
Sample Composite resin Polymerization Staining Immersion time Bleaching agents used Measuring system Evaluation of color
size method media
Erturk‑Avunduk 80 A nanohybrid Light‑emitting Each 20 ml 3 hours/day at Opalescence Boost (HP CIEDE2000 system The nanohybrid composite
et al., 2022[10] composite and diode curing of tea, coffee, room temperature 40%), Opalescence Spectrophotometer, exhibited an acceptable
bulk‑fill resin (Planmeca red wine, over a 30‑day PF (CP 16%) VITA Easyshade V, change than the bulk‑fill
composite Lumion, Planmeca and distilled staining period VITA Zahnfabrik, Bad resin composites (p<0.05).
materials Oy, Helsinki, water (C) Säckingen, Germany Fiber‑reinforced
Finland) bulk‑fill (eXP) and
nanohybrid conventional
RC are more prone to
discoloration. Coffee and tea
exerted more staining than
distilled water and red wine,
except for the eXP group.
Mota et al., 90 Nanofilled Light‑cured 200 ml each At 37°C for 48 h. 20% CP (Opalescence CIEDE2000 Stained RC exhibited
2020[20] composite (Bluephase – of red wine, PF), 38% system (hand perceptible but unacceptable
Ivoclar Vivadent, coffee, and HP (Opalescence spectrophotometer, color and whiteness changes,
Barueri, São Paulo, artificial saliva Boost), or no bleaching VITA Easyshade, regardless of the bleaching
Brazil) VITA‑Zahnfabrik, treatment. Bleaching was
Germany), color unable to reverse the color
alteration (∆E00), and changes produced by red wine
whiteness index (∆ WID) and coffee
Araújo et al., 80 Bulk‑fill Photoactivated Coffee For 36 hours, 35% HP (in‑office CIELab system using The ΔE showed higher values
2019[21] composite, (Radii Cal, SDI) solution stored in closed bleach; three Spectrophotometer for the home‑bleaching
bulk‑fill fluid resin, bottles in a applications for (VITA EasyShade®, groups. Bulk‑fill resins do
conventional resin, bacteriological 15 minutes at 7th, VITA‑Zahnfabrik not guarantee greater color
and conventional oven at 37°C 14th, and 21st day), H. Rauter GmbH stability than the other RC
flow resin 22% CP for one & Co. KG, Bad tested. The conventional RC
hour for 14 days (at Säckingen‑Germany) showed the lower ΔE
Althaqafi and Alshabib: Discoloration of composite resins

home‑bleach)
Zhao et al., 70 Nanofilled Light cured Cigarette A 56‑min 6% HP (commercial CIELab system Red wine and CS cause more
2019[22] universal smoke (CS), exposure to the take‑home Olympus color mismatch between
composite electronic CS, equivalent to tooth‑whitening gel) Crystaleye dental enamel and RC that cannot
resin (shade A2 cigarette (EC), 224 puffs, 75‑min for 30 minutes/day spectrophotometer be corrected by whitening
enamel) red wine, exposure to the EC for 8 days, for a total (Olympus, Tokyo, treatments. Although minor
coffee, and aerosol, equivalent of 240 minutes; and Japan) color changes caused
soy sauce to around 300 35% HP, in‑office by EC aerosol could be
puffs, and bleach (30 minutes/ eliminated by brushing with
for 56 min/day session for 2 sessions) a tooth‑whitening toothpaste
for 15 days s at alone, whitening with 6% and
35% H2O2 was necessary to

Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023

22±1°C for red
wine, coffee, and reverse discoloration caused
soy sauce. by coffee and soy sauce.

S5
Contd...
 S6
Table 2: Contd...
Sample Composite resin Polymerization Staining Immersion time Bleaching agents used Measuring system Evaluation of color
size method media
Hasani et al., 40 Microhybrid, Light cured Coffee, 0.2% Coffee‑20 minutes/ Opalescence Boost CIELab system using Coffee produced more color
2019[23] nanohybrid, (Optilux 501 LC; chlorhexidine day; CHX‑ one 40% HP (office bleach), spectrophotometer changes than CHX except
nanofill composite Kerr Corp, Orange, (CHX) minute/day for one Opalescence 10% (X‑Rite, Grand Rapids, stained Z550 by coffee in
materials CA, USA) month CP (home bleach) MI, USA) home bleaching groups.
A significant∆E was noted
in CHX groups by both the
bleaching agents
Sunildath et al., 36 Nanohybrid Light cured 50 ml each For seven days Crest 3D white CIELab system using A significant difference in∆E
2019[24] composite resin of coffee, toothpaste (Procter and spectrophotometer imparted following bleaching
turmeric Gamble Cincinnati, (SpectroShade Micro II, with crest 3D white toothpaste
solution, and OH, United States); MHT, Switzerland) after staining with coffee and
distilled water Polanight 22% (SDI turmeric solution.
Polanight Australia);
Polaoffice 35% HP (SDI
Limited, Bayswater,
Victoria, Australia);
Shofu polishing kit
Gul et al., 50 A2 shade Elipar FreeLight Coffee and All the samples BIOLASE CIEDE 2000 system The highest reversal effect
2017[25] nanohybrid S10, 3M ESPE, St. turnip juice were immersed in Laserwhite20; Ultradent using spectrophotometer of∆E was determined in office
universal Paul, MN, USA coffee for 1 week Opalescence Boost (VITA Easy shade bleaching system. However,
composite and subsequently 40%; Ultradent Compact, VITA home and laser bleaching
in turnip juice for Opalescence PF 15% Zahnfabrik, Bad systems were found to be as
an additional week home bleaching; Crest Säckingen, Germany) effective as office bleaching
3D White Whitening system
Mouthwash and distilled
water
Althaqafi and Alshabib: Discoloration of composite resins

Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023

Lago et al., 60 Enamel LED light source 4 ml each of At 37°C for 16% CP (Mix Night) CIEDE2000 method A significant effect of
2017[15] shades (A2E) (Flash Light, deionized 14 days and 35% HP (Mix One)using spectrophotometer bleaching was observed for
and dentin Discus, Culver water and red (SP60 X‑Rite) RC exposed to red wine. CP
shades (A2D) City, CA, USA) wine had better bleaching results
Filtek Z350 XT with stained RC than HP
Farah and Elwi, 54 Nanofilled Filtek Halogen curing Distilled Immersed at 55°C 10% and 16% CP (Zoom CIELab system using Nanofilled composites
2014[26] Z350 XT, and a light QHL75 water, tea, and in the coffee and NiteWhite amorphous spectrophotometer discolored more than
nanohybrid Tetric Curing Light coffee tea groups and calcium phosphate), and (VITA Easyshade, nanohybrid composite.
N‑Ceram, in the (Dentsply Caulk, at 37°C in the 25% HP gel (Zoom 2) VITA Zahnfabrik, Bad CP‑based bleaching agents
extra‑white body Milford, DE, USA) distilled water with light activation Säckingen, Germany) were effective in reducing the
shade XWB, and group over a 7‑day discoloration to a clinically
L‑shades test period acceptable value
 Althaqafi and Alshabib: Discoloration of composite resins

Table 3: Summary of restorative materials used and polymerization protocol

Product Manufacturer Viscosities Time and Irradiance
Erturk‑Avunduk C: Clearfil Majesty Kuraray Noritake Dental Inc.; Nanohybrid 1070 mW/cm2 at a duration
et al., 2022[10] Posterior Okayama, Japan Bulk‑filled flowable recommended by the
E: SDR flow+, Dentsply, Germany manufacturer
Bulk‑filled flowable
Filtek Bulk Fill 3‑M Espe, MN, USA Bulk‑fill posterior restorative
Restorative Bisco Inc; Schaumburg, IL, Bulk‑fill posterior restorative
Reveal HD Bulk USA
Bulk‑fill posterior restorative
Beautifil‑Bulk Restorative Shofu Inc, Koyota, Japan
Hybrid Bulk‑fill composite
Tetric EvoCeram Bulk Fill Ivoclar, Vivadent,
Short fiber reinforced
SonicFill 2 Liechtenstein
Bulk‑filled flowable
EverX Posterior Kerr Corp; Orange, CA, USA
Bulk‑filled flowable
Xtra base GC Corporation, Tokyo,
Bulk‑filled flowable
Japan
Venus® Bulk Fill
Voco, Cuxhaven, Germany
Heraeus Kulzer GmbH,
Hanau, Germany
Mota et al., Filtek Z350XT, 3M/Oral Care, São Paulo, Nanocomposite (Universal Light‑cured for 40 s, 1,200
202020 Brazil restorative) mW/cm2 of irradiance
Araújo et al., Filtek Z350XT 3M ESPE, St. Paul, MN, USA Nanocomposite (conventional) Photoactivated for 20 seconds
2019[21] Filtek Bulk Fill 3M ESPE, St. Paul, MN, USA Bulk‑fill composite resin
Grandio SO Flow VOCO, Cuxhaven, Germany Conventional flow resin
Filtek Bulk Fill Flow 3M ESPE, St. Paul, MN, USA Bulk‑fill fluid resin
Zhao et al., Filtek Supreme Ultra and 3M ESPE Nanofilled universal NR
2019[22] Scotchbond universal composite
adhesive
Hasani et al., Filtek Z250 3M ESPE, St. Paul, MN, USA Microhybrid For 40 seconds with Halogen
2019[23] Filtek Z550 Nanohybrid light curing unit
Filtek Ultimate Nanofill
Sunildath et al., GC Solare Sculpt A2 NR Nanohybrid NR
2019[24] shade
Gul et al., Filtek Z550 3M ESPE, St. Paul, MN, USA Nanohybrid universal Photopolymerization was
2017[25] restorative performed for 20 s with a LED
curing light
Lago et al., Filtek Z350 XT 3M ESPE, St. Paul, MN, USA Nanocomposite Photoactivated for 20 seconds
2017[15] through the glass plate, and
20 seconds without it, by
a LED light source with
approximately 800 mW/cm2,
measured by a LED radiometer
Farah and Elwi, Filtek Z350 XT 3M ESPE, St. Paul, MN, USA Nanofilled For 40 seconds
2014[26] Tetric® N‑Ceram Ivoclar/Vivadent AG, Schaan, Nanohybrid
Liechtenstein

has been found that nanohybrids have smaller gaps on microhybrid and hybrid composites. Farah and Elwi[26]
the surface that debond from the resin. Differences in also stated that the color of the nanohybrid RC was
resin hues, curing conditions, viscosity of the RC, and least influenced by the immersed media, whereas the
specimen storage procedures during observation, color color of the nanofilled resin was the most affected.
measuring tools, and observation methodologies also This observation can be attributed to the fact that the
influence color variations.[25] nanofilled resins were more light‑colored than the
Extrinsic factors include exposure to pigmented food, nanohybrid composites. The paler materials discolor
ultraviolet radiation, changes in temperature, and water more remarkably than darker shades. The resin
sorption.[2] According to Karadas et al.,[2] the nanohybrid matrix utilized in the RC also has an impact on stain
composite had the least discoloration, preceded by the propensity.[26] The shade of the RC used was clearly

Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023 S7

 Althaqafi and Alshabib: Discoloration of composite resins

mentioned only in the respective studies conducted by

score (%)

24 (100)

21 (88)

21 (88)

19 (79)

21 (88)

18 (75)

19 (79)

22 (92)

23 (96)
Total
Zhao et al.,[22] Lago et al.,[15] and Gul et al.[25] A2 shade
was chosen in all these studies to minimize the effect of
shade on color durability.
tests applied presentation
Soundness of data analysis

The probable discoloration caused by salivary

Data

constituents is minimized by preserving the samples at

2

2
37°C in distilled water. According to Araújo et al.,[21]
Table 4: Quality assessment scores of included studies: classification of level of evidence (maximum score of 24 points)

bulk‑fill resins do not provide superior durability

than other RC, including conventional flow polymer.
Immersion Color quantification Statistical

The bleaching strategy is primarily dependent on the

1

1
oxidation of HP or its progenitors, which are frequently
employed in conjunction with a chemically active
catalyst, heat, or light.[29] In the last decade, there has
been an upsurge in the usage of peroxide‑containing
home bleaching treatments. Commercialized home teeth
method

bleaching therapies are often delivered in the form of a

2

2
gel and are manufactured using 15% CP.[30] Gul et al.[25]
used a laser‑powered bleaching agent with 45% HP.
The laser is widely regarded as the most effective form
Methodological soundness

for in‑office bleaching and is noteworthy for its speedy

and simplistic application. Laser‑driven bleaching was
time
3

reported to be 1.88‑folds more powerful than other

methods of professional bleaching for the reversal of
color incompatibility.[31]
polymerization
Protocol of

The use of coffee as an artificial staining solution

promotes the production of spots by absorption and
3

adsorption and discolors the teeth as well as RC

significantly. Moreover, the coffee stains are highly
resistant to removal from the RC when compared
Sample size Randomization Study Objectives Composites

to staining with tea or wine.[5,21] The prime cause of

used
2

discoloration is due to the presence of melanoidins,

which are brown higher molecular nitrogenous
chemicals generated during the roasting of coffee
stated

powder. Other colorants, such as tannin and caffeine,

1

enhance staining because they permeate deeply into

the RC. Tea also promotes RC discoloration owing to
groups

the tannin adsorption.[32] Sunildath et al.[24] claimed that

6

crest 3D tooth whitening dentifrices outperformed all

Study design

other bleaching treatments in the specimens stained with

turmeric and coffee.
Coffee,[10,20‑26] red wine,[10,15,20,22] tea,[10,26] turnip juice,[25]
1

soy sauce,[22] chlorhexidine,[23] and turmeric[24] were

utilized as staining agents in the included studies,
which could modify the color of tooth or RC, notably
if consumed often. Due to the abundance of flavonoids,
3

lower pH, and alcoholic content, red wine is claimed

to be the most powerful color‑altering solution among
artificial staining agents.[33,34] Thus in addition to
Erturk‑Avunduk

Farah and Elwi,

Sunildath et al.,
et al., 2022[10]

the discoloration caused by exogenous staining, the

Article, Year

Araújo et al.,

Hasani et al.,
Mota et al.,

Zhao et al.,

Lago et al.,

aging process may also cause roughened RC surface.

Gul et al.,
2020[20]

2019[21]

2019[22]

2019[23]

2019[24]

2017[25]

2017[15]

2014[26]

Consequently, the roughened surface increases the

likelihood of biofilm adhesion leading to recurrent caries

S8 Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023

 Althaqafi and Alshabib: Discoloration of composite resins

development.[20,35] Tobacco‑smoke‑induced visible color dependent on the RC utilized. Within the limitations
alterations in the tooth as well as in the RC are believed of the in‑vitro investigations, it was deduced that the
to worsen with prolonged use since the ΔE values bleaching agents were successful in eliminating the
increase over time.[22] stains and improving the durability of the color to near
baseline values.
Though the enamel discoloration was eventually
corrected, subsequent treatments with 6% and 35% HP
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S10 Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023