journal of dentistry 38s (2010) e17e24

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

Review

Whitening toothpastes: A review of the literature

Andrew Joiner *
Unilever Oral Care, Quarry Road East, Bebington, Wirral CH63 3JW, UK

article info

abstract

Article history:

Objectives: To review and summarise the whitening agents contained within tooth whiten-

Received 9 March 2010

ing toothpaste formulations, their mode of action in tooth whitening, and the in vitro and

Received in revised form

clinical methods used to evaluate and demonstrate their efficacy.

16 May 2010

Methods: Original scientific full papers or reviews listed in ISI Web of Science and Medline

Accepted 17 May 2010

were included in this review using the search terms white*, toothpaste and dentifrice.
Conclusions: Due to the reported consumer and patient dissatisfaction with their perceived
tooth color, toothpaste manufacturers have responded by developing a vast array of

Keywords:

contemporary whitening toothpastes. One of the key functional ingredients in whitening

Tooth whitening

toothpastes is the abrasive system. In general, these have been designed to give effective

Bleaching

removal of extrinsic stains and help prevent tooth stains from reforming without undue

Perception

abrasivity towards the dental hard tissues. Whitening toothpastes may contain additional

Aesthetics

agents that augment the abrasive cleaning by aiding the removal and/or prevention of

Toothpaste

extrinsic stains, for examples, peroxide, enzymes, citrate, pyrophosphate and hexameta-

Dentifrice

phosphate, or optical agents such as blue covarine which can improve tooth whiteness
following tooth brushing. In vitro methods used to evaluate tooth whitening efficacy
typically determine the ability of a toothpaste formulation to remove/prevent model
extrinsic stains on substrates such as enamel or hydroxyapatite or changes in the intrinsic
color of tooth specimens. Clinical protocols for evaluating the efficacy of whitening toothpastes typically determine either stain removal or prevention, where changes in natural
stain or chlorhexidine/tea induced stain are measured typically over 26 weeks. In some
clinical studies the overall tooth color change was measured using techniques such as Vita
shade guides, colorimeters and image analysis of digital photographs of teeth.
# 2010 Elsevier Ltd. All rights reserved.

1.

Introduction

The color of the teeth is influenced by a combination of their

intrinsic color and the presence of any extrinsic stains that
may form on the tooth surface.1,2 Intrinsic tooth color is
greatly influenced by the light absorption and scattering
properties of the enamel and dentine, with dentine playing a
significant role in determining the overall tooth color.3,4
Extrinsic color is linked with the adsorption of materials into
the acquired pellicle on the surface of enamel, which

ultimately cause staining.5 Factors that influence extrinsic

stain formation include poor tooth brushing technique,
smoking, dietary intake of colored foods (e.g. red wine),
subject age and the use of certain cationic agents such as
chlorhexidine or metal salts like tin and iron.1,58
Consumers and patients alike have always had a strong
desire for white teeth and many individuals are dissatisfied
with their current tooth color as indicated in a number of
recent studies.911 Depending on the population examined,
these studies have shown that personal dissatisfaction with

* Tel.: +44 0151 641 3000; fax: +44 0151 641 1800.
E-mail address: Andrew.Joiner@Unilever.com.
0300-5712/$ see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2010.05.017

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journal of dentistry 38s (2010) e17e24

tooth color ranges from 17.9 to 52.6%. This desire for whiter
teeth has given rise to a growing trend in the increased use of
tooth whitening products.12,13 Manufacturers of oral care
products are constantly developing improvements and new
approaches for tooth whitening in order to meet the
demanding expectations of patients and consumers. Thus,
today there is a huge range of product types and technologies
addressing the problem of tooth discoloration available on the
market. The majority of these products work in one of two
ways, either by bleaching of the teeth, or by the removal and
control of extrinsic stain. Tooth bleaching typically involves
the application of hydrogen peroxide or carbamide peroxide
containing gels to the teeth through various formats, including
a mouth guard or strip or even painting directly on. The
peroxide causes decolorisation or bleaching of the colored
materials found within the tooth giving rise to whiter teeth.14
In order to optimise the removal and control of extrinsic stain,
specific abrasives and/or chemical agents can be added to
toothpaste. These improved stain removal/prevention products are termed whitening toothpastes.
The purpose of the current review is to summarise the
available literature concerning the technology contained in
tooth whitening toothpaste formulations, their role in tooth
whitening, and in vitro and clinical methods used to evaluate
and demonstrate their efficacy. Only original scientific full
papers or reviews listed in ISI Web of Science and Medline
were included in this review using the search terms white*,
toothpaste and dentifrice. The total number of studies
identified which described the technology behind whitening
toothpastes and their efficacy was 57, of which 22 were in vitro
studies and 35 were clinical studies. The majority of studies
(89%) were published from 1998 onwards. Most of the clinical
studies investigated natural extrinsic stain removal and/or
prevention (69%), with clinical sample sizes in the range 22
219 subjects, although typically of the order 3060 subjects and
durations typically of 26 weeks, but sometimes prolonged for
12 weeks or more. Other clinical studies investigated the
impact of whitening toothpastes on chlorhexidine induced
stain (20%) or to a lesser extent on intrinsic tooth color (11%).

2.

Whitening toothpastes

Oral care product manufacturers are well aware of the

consumer dissatisfaction with their perceived tooth color
and, in response, have developed a vast choice of contemporary toothpastes to address the problem. Most contain the
same basic functional ingredients, all of which have a specific
role to play within the formulation. These include: solid
cleansing abrasive materials, humectant for solubilisation of
other ingredients and to prevent the formulation from drying
out; thickening agent to define the rheological properties of
the formulation; surfactant to generate foam and impart
desirable sensorial properties during use, active agents such
as fluoride to provide health benefits, flavour, sweetener,
opacifying agents; colors for characteristic taste and appearance; and buffering agents and preservative to maintain
formulation stability.15
In general, toothpastes that are specifically formulated for
tooth whitening provide this benefit by removing and prevent-

Table 1 Tooth whitening agents.

Abrasives

Hydrated silica
Calcium carbonate
Dicalcium phosphate dihydrate
Calcium pyrophosphate
Alumina
Perlite
Sodium bicarbonate

Chemical

Hydrogen peroxide
Calcium peroxide
Sodium citrate
Sodium pyrophosphate
Sodium tripolyphosphate
Sodium hexametaphosphate
Papain

Optical

Blue covarine

ing the formation of extrinsic stain. It is well documented that if

a very low abrasive toothpaste is used, stained pellicle usually
accumulates on the surfaces of teeth16 and it is now widely
accepted that toothpastes require a certain amount of abrasivity to remove or prevent extrinsic stains from forming.1618
Other toothpaste ingredients have been described in the
literature for removing and preventing extrinsic stain including
surfactants, polyphosphates and enzymes (Table 1). However,
the evidence to date still suggests that the primary stain
removal ingredient in toothpaste is the abrasive.15

3.

Evaluation of whitening toothpastes in vitro

The evaluation of tooth whitening using in vitro models is

important as it allows the initial testing of scientific hypotheses and the rapid screening of many different types of
materials and prototype formulations. This can lead to the
optimisation and ultimately the identification of efficacious
whitening toothpaste formulations. In addition, in vitro models
have proven useful as they can be used to develop mechanistic
insights and to gain important information on the safety of
products, for example, in terms of their effects on the dental
hard tissues.
A number of tooth whitening in vitro models evaluating the
effects of toothpaste have been reported in the literature.
These typically determine the ability of a toothpaste formulation to remove a model extrinsic stain from a substrate such as
enamel or hydroxyapatite, although other methods have been
described which evaluate stain prevention approaches or
changes in the intrinsic color of tooth specimens following
extensive brushing times.
One of the most commonly used methods for assessing the
stain removal by toothpaste in vitro is the method developed by
Stookey et al.16 This model uses square bovine enamel blocks
mounted in polymethylmethacrylate blocks. The specimens
are polished and lightly acid etched in order to facilitate stain
accumulation and adherence. They are attached to a staining
apparatus which provides alternate immersion into a staining
media and air drying at 37 8C. The staining media consists of tea,
coffee, gastric mucin, sterilised trypticase soy broth and Sarcina
Lutea bacterial culture. After a number of days, the stained
specimens are assessed by visual means using a five-point scale

journal of dentistry 38s (2010) e17e24

or the color of the specimens may be measured objectively with

a colorimeter.13,19,20 The stained specimens are then mounted
in a mechanical brushing machine and the required load
applied to each brush. The test toothpastes are dispersed in an
aqueous diluent and the stained specimens brushed for a set
number of brush strokes. The color of the specimens is
remeasured and from these values the amount of stain
removed may be calculated. These values are sometimes
referred to as the Pellicle Cleaning Ratio (PCR).19,20 A number
of variations of this method have been described including
using only black tea in the staining media21,22 and the use of
50 8C in the staining procedure.13
A ferric-tannate coating on hydroxyapatite discs are used
as the substrate in the stain model described by Dawson
et al.23 This model is reported to simulate relatively immature
1224 h old pellicle films found on smooth surfaces and thus
mimics the daily control of pellicle growth, maturation and
staining. Indeed, it has been shown that the cleaning values
obtained from this model correlate well with the clinically
measured stain prevention over 6 weeks of four toothpastes
containing a range of levels of abrasive silica.23
An in vitro model based on 0.2% chlorhexidine enhanced tea
staining on saliva coated methyl methacrylate blocks has been
described for the evaluation of stain formation/stain removal
of toothpaste ingredients and formulations under nonbrushing conditions.2426 The blocks are designed to fit a
UV/visible spectrophotometer and the level of stain determined at the lambda maximum of the tea solution.
Extracted human teeth have been used as the substrate in
the evaluation of tooth whitening where the toothpaste has
been designed to have an effect on the average intrinsic tooth
color. Initially, the teeth are thoroughly cleaned with a
prophylaxis paste to remove any traces of surface extrinsic
stain followed by a brushing protocol with the test toothpaste.
Changes in intrinsic tooth color can be measured with a
colorimeter, spectrophotometer or by comparison with a Vita
shade guide under controlled lighting conditions.2730

4.

Evaluation of whitening toothpastes in vivo

The clinical evaluation of whitening toothpastes involving

extrinsic stain measurement usually falls into one of two types
of protocols, namely stain removal or stain prevention. For
stain removal, subjects may be recruited with sufficient levels
of pre-existing extrinsic stain3139 or have extrinsic stain
induced via the rinsing with a chlorhexidine containing
mouthwash and tea solutions.4042 Subjects are then allocated
their test toothpaste and are typically instructed to brush their
teeth twice/day. The reduction in the levels of extrinsic stain
for the test toothpaste is determined usually over a period of 2
6 weeks. For stain prevention, subjects are initially given a
prophylaxis treatment at baseline to remove any extrinsic
stain present on their teeth. Subjects then use the allocated
test toothpaste and natural32,36,4345 or chlorhexidine4648
induced extrinsic stain formation is measured over time.
The product efficacy is determined by its relative ability to
prevent or reduce the formation of extrinsic stain over time.
The methods used to measure extrinsic stain levels in
clinical studies include subjective clinician determinations

e19

and objective instrumental methods. The most commonly

used clinician measurement is the Lobene Stain Index.49 This
index provides measures of both the area and intensity of
extrinsic tooth stain on the facial and lingual surfaces of
anterior teeth. The surfaces of the teeth are divided into
gingival and body regions with the intensity and area assessed
using 03 scales. Modifications of the Lobene Stain Index to
increase discriminator power have been described50 as well as
alternative stain indices.51,52 In terms of determining the
overall average tooth color or shade change following the use
of whitening toothpastes, a number of techniques have been
described including the use of Vita shade guides,39,45,53
colorimeters34,44,54,55 and image analysis of digital photographs of teeth.5659 Regardless of the methodology employed,
important factors in stain assessments include the calibration
and standardisation of objective measures and/or the demonstration of reproducibility and sensitivity in subjective
indices.12

5.

Abrasives

Abrasives are the insoluble components added to toothpaste

in order to aid the physical removal of stains, plaque and food
debris. Abrasives used in toothpaste date back over 2000 years
where preparations using bones and ground shells have been
described.60 In contemporary toothpastes, the abrasives used
include hydrated silica, calcium carbonate, dicalcium phosphate dihydrate, calcium pyrophosphate, alumina, perlite and
sodium bicarbonate.61 Abrasives have been shown to effectively remove extrinsic stains but also can help in preventing
tooth stains from reforming when cleaned areas are brushed
to remove immature stains.12 During tooth brushing, the
abrasive particles can become trapped between the toothbrush bristle and the stained tooth surface.62 Since the
abrasive is physically harder than the stain, the stain can be
removed leaving a cleaned tooth surface. It is clear from this
mechanism that abrasive cleaning primarily influences only
extrinsic stains and does not greatly influence any underlying
intrinsic discoloration or the natural shade of the tooth.
Abrasive cleaning may be further limited by the accessibility of
the toothbrush to stained areas of the teeth, particularly in
interproximal areas, gingival areas and malocclusion sites.
There are a number of key parameters that have been
demonstrated to affect the abrasive cleaning process, including particle hardness, shape, size, size distribution, concentration and applied load.15 For example, it has been shown that
the abrasive wear rate increases linearly as the particle size
increases up to a critical size and then becomes independent
of size.63,64 If the abrasive particles are too large they will
become ineffective as an abrasive since they will not be
captured by the toothbrush bristle and will be swept aside.
Similarly, as the particle concentration increases the abrasion
will increase until the chances of particles being captured by
the brush approaches unity. Any further addition of particles
will be ineffective at increasing the rate of abrasion and the
stain removal efficacy will approach a plateau level.23,65
Toothpaste abrasion towards the dental hard tissues is an
important factor for whitening toothpaste design in terms of
the trade off between cleaning efficacy and tooth wear. There

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journal of dentistry 38s (2010) e17e24

are a number of in vitro, in situ and in vivo methods for

measuring toothpaste abrasion towards enamel and dentine
and these have been extensively reviewed.6668 The relative
safety of abrasives is characterised by established international standard methods based on enamel and dentine,
referred to as the Radioactive Dentine Abrasion (RDA) and
Radioactive Enamel Abrasion (REA) methods.61,69 These
methods compare the toothpaste abrasivity with a standard
abrasive material acting as a control. This gives a normalised
scale for toothpaste abrasivity with defined maximum values
that would be considered safe for consumers to use assuming
a lifetime of ordinary tooth brushing.66
The understanding of the abrasive action and cleaning of
extrinsic tooth stain has enabled oral care product manufacturers to continually develop optimised levels of abrasives
within toothpaste formulations, carefully tailored to meet
specific consumer needs in terms of the level and speed of the
tooth whitening achieved, whilst moderating the abrasivity of a
toothpaste towards the dental hard tissues. In this way,
whitening toothpastes have been designed to maximise
cleaning whilst minimising hard tissue wear. For example, an
improved soft silica abrasive has been described12 which has
both reduced hardness (conventional silica = 5.9; soft silica = 4.2) and dentine abrasion (conventional silica RDA = 110,
soft silica = 87). When incorporated into a toothpaste
formulation, in vitro PCR studies indicated a significant
improvement in cleaning compared to conventional silica
formulations.19 This result was further confirmed in a chlorhexidine/tea induced stain removal clinical study over 6
weeks42 and a natural stain prevention clinical study over 3
months.44 Other developments in silica abrasive technology
include a high cleaning silica engineered to give maximum stain
removal whilst not being unduly abrasive on teeth.70 When
incorporated into a toothpaste formulation, it gave significant
removal of existing natural extrinsic stain over 6-weeks
compared to a conventional silica control toothpaste.35,71,72
Combinations of abrasives have been described and are
also shown to be efficacious. For example, a dual silica system
consisting of 17% high cleaning silica and 17% polishing silica
in a toothpaste formulation gave significantly lower levels of
natural extrinsic stain after 3 and 6 weeks of product use
compared to a conventional silica control toothpaste in both a
stain removal and a stain prevention clinical study.36 In a
clinical study using a population with high-levels of preexisting extrinsic stain, significant stain reductions were
observed with the dual silica system after 1- and 2-weeks
product use compared to a control silica toothpaste.73
Perlite, an amorphous glassy silicate used as a polishing
agent in prophylaxis products, when incorporated into a silicabased toothpaste was shown to give a significant improvement
in stain removal properties when compared to a control silica
toothpaste in both in vitro and clinical studies.32 The enamel
wear of this formulation was evaluated using an in situ protocol
and it was concluded that the enhanced tooth whitening
benefits did not give rise to a concomitant significant increase in
enamel wear compared to a non-whitening control silica
toothpaste.32,74 Perlite has also been incorporated into a
calcium carbonate based whitening toothpaste and has been
shown in clinical studies to significantly remove existing
natural extrinsic stains after 2 weeks31 and 4 weeks33 of

toothpaste use versus control toothpastes. This product was

also shown not to give a clinically relevant level of wear to
enamel or a significant increase in dentine wear compared to a
marketed non-whitening toothpaste.75,76

6.

Chemical agents

Whitening toothpastes may contain additional chemical

agents which augment the abrasive cleaning by aiding the
removal and/or prevention of extrinsic stains. Ingredients
studied previously include surfactants, peroxide, enzymes,
citrate, pyrophosphates and hexametaphosphate.
The intrinsic tooth whitening efficacy of peroxide is well
established in certain delivery formats such as trays, strips
and paint-on14 whereas the application of peroxide in
toothpaste is much more challenging in terms of formulation
factors and the relatively shortened exposure times.77 However, despite these challenges, toothpastes containing oxidative chemistries such as peroxide, peroxide sources and
sodium chlorite have been described.78,79 For example, a 1%
hydrogen peroxide/sodium bicarbonate toothpaste was
shown to significantly decrease tooth yellowness (b*) and
increase lightness (L*) of tooth samples in vitro compared to a
silica and sodium bicarbonate control toothpaste.27 Further, a
toothpaste containing 0.5% calcium peroxide has been shown
to significantly reduce natural extrinsic stain versus a placebo
toothpaste after 6 weeks of product use.80 Another example is
a toothpaste packaged into a dual-chambered container
where one stream is a formulation containing 1% hydrogen
peroxide and the other stream is a formulation containing
high cleaning silica, phosphate salts and manganese gluconate which can activate the peroxide during use.79 This
toothpaste has been shown to whiten teeth in a series of in
vitro studies79; significantly remove more extrinsic stain
versus a silica control toothpaste after 2 and 4 weeks53;
significantly remove more extrinsic stain and give a greater
reduction in mean tooth shade than a silica/hexametaphosphate containing whitening toothpaste after 6 weeks,39 and
significantly prevent extrinsic stain formation versus a silica/
hexametaphosphate whitening toothpaste.45
Due to extrinsic stain being primarily incorporated into the
pellicle, a salivary protein film that forms on the tooth surface,
it is possible that enzymes such as proteases could help
degrade the stained films and potentiate their removal. Early
clinical evidence in the 1960s demonstrated that a highly
proteolytic mixture of enzymes of fungal origin formulated
into toothpaste was effective at reducing extrinsic stain
compared to a negative control toothpaste after 6 months of
product use.81 More recently, a toothpaste containing a
mixture of the protease enzyme papain, alumina and sodium
citrate has been described in the literature. Although an early
clinical study showed no significant effect of this toothpaste
on removing established extrinsic stain versus a placebo
toothpaste,82 further clinical studies have demonstrated the
combination toothpaste to be effective at removing established stains,83 more effective at removing established
extrinsic stain than a tartar control toothpaste,84 and more
effective at removing chlorhexidine induced stain than a
control toothpaste.85

journal of dentistry 38s (2010) e17e24

Phosphate materials, such as pyrophosphate, tripolyphosphate and hexametaphosphate, tend to have a strong binding
affinity for enamel, dentine and tartar, and during adsorption
they have been shown to desorb stain components.86,87
Sodium pyrophosphate alone has been utilised in whitening
toothpastes, although primarily for their anti-tartar activity.19
Sodium tripolyphosphate (STP) has been incorporated into
whitening toothpastes either on its own or in combination
with pyrophosphate.43,8890 In a direct comparison, a whitening toothpaste containing a combination of STP and pyrophosphate gave a significantly greater reduction of preexisting extrinsic stain than a whitening toothpaste containing only STP, with both products significantly better than a
regular silica toothpaste.89,90 In other clinical studies, the STP/
pyrophosphate containing whitening toothpaste has also
been shown to remove significantly more pre-existing extrinsic stain than a non-whitening silica control.43,88
Sodium hexametaphosphate (HMP) is a longer chain
variant of pyrophosphate containing 1012 repeating pyrophosphate subunits. It has multiple binding sites which have
the potential to increase its retention and substantivity to
tooth surfaces compared to pyrophosphate and potentially
reduce stain-chromogen adsorption to the tooth surface.77
Indeed, in vitro studies have shown the ability of HMP to reduce
the adsorption of tea chromogens onto hydroxyapatite
powder and discs.91 A toothpaste containing 5% HMP as anion
was shown in clinical studies to significantly remove
chlorhexidine/tea induced stain versus control toothpastes
after 3 and 6 weeks product use.40,41 Stain prevention benefits
of HMP in a toothpaste have also been demonstrated in a 6week clinical study.47 In addition, HMP has been incorporated
into other whitening toothpaste formulations where it has
also been shown in clinical studies to give improved stain
removal benefits.37,38,92,93

7.

Optical routes

A yellow to blue tooth color shift (i.e. reduction in b*) is

reported in a number of in vivo and in vitro whitening studies to
be important in aiding the overall self-perception of tooth
whiteness.94 This observation has been applied in the
development of a silica whitening toothpaste containing
blue covarine.29,95 Following brushing extracted teeth in vitro,
the blue covarine has been shown to be deposited onto the
tooth surface and to give a yellow to blue color shift with an
overall improvement in measureable and perceivable tooth
whitening.29 This toothpaste has also been shown to have an
effective abrasive system for removal of extrinsic stain
compared to other clinically proven silica-based whitening
toothpastes.96 Further, Collins et al.57 demonstrated in a
clinical study that brushing once with the toothpaste
containing blue covarine can give a significant and immediate
reduction in tooth yellowness (b*) and an increase in tooth
whiteness (WIO Index) compared to baseline and a control
silica toothpaste, as measured by image analysis of digital
photographs of the teeth. Thus, the silica-based toothpaste
containing blue covarine is not only effective in removing
extrinsic stains but also in significantly whitening the
intrinsic color of teeth.

8.

e21

Concluding remarks

The last decade or so has seen the publication of the majority

(89%) of the efficacy studies on whitening toothpastes
indicating the contemporary importance of these types of
products for consumers, patients, researchers and manufacturers alike. In terms of the technology used in whitening
toothpastes, one of the key functional ingredients is the
abrasive system. This has been augmented with other
chemical or optical ingredients and in general whitening
toothpastes have become complex formulations with multiple
combinations of these ingredients in order to deliver improved
whitening benefits. It is also noted that in general these
formulations contain a fluoride source which can provide
enamel health benefits.77,79,88,90,92,95
There are various types of in vitro models for evaluating
whitening toothpastes and these may have some limitations,
especially when considering the in vivo situation, for examples: uses only one type of model stain; often uses extended
and exaggerated brushing times; substrates are often flat and
do not mimic interproximal regions, and no dilution of
toothpaste during brushing. However, despite these limitations, the literature does describe a number of positive links
between in vitro efficacy and clinical efficacy. Indeed, it can
often be observed in the literature the development of a new
whitening technology/formulation from its initial in vitro
testing through to the final clinical testing.
There are various clinical methods and models used to
investigate whitening toothpaste efficacy. These usually
determine either stain removal or prevention, where changes
in natural stain or chlorhexidine/tea induced stain are
measured typically over 26 weeks. In some clinical studies
the overall tooth color change was measured using techniques
such as Vita shade guides, colorimeters and image analysis of
digital photographs of teeth. Most clinical studies compare the
efficacy of a tooth whitening formulation with a nonwhitening control formulation. There are only a few studies
comparing different technologies in the same clinical. This
may be due to the time and cost of conducting clinical studies
with additional product cells or indeed the relevance of such
studies since the whitening toothpaste market is very
dynamic with ever changing toothpaste formulations. It can
also be difficult to compare clinical results from one study to
another due to a number of possible factors including:
different stain indices being used; differences in subject
demographics, smoking and eating habits; study protocol
differences, and so on.
The duration of most stain removal/prevention studies is
typically in the range 26 weeks with a few studies measuring
whitening effects up to 12 weeks or longer. There appears to be
little information on the longer term maintenance and
stability of the tooth whitening effects and no studies
evaluating stain levels following the use of a whitening
toothpaste and then switching to a non-whitening toothpaste.
In addition, there is limited information on subject perception
of the tooth whitening improvements achieved by whitening
toothpastes.
With the continued interest in tooth whitening by
consumers and patients, together with continued research
in tooth color, extrinsic stain, new whitening technologies and

e22

journal of dentistry 38s (2010) e17e24

measurement techniques, these will combine to make the

further development of next generation tooth whitening
products a reality and a benefit to the field of aesthetic
dentistry.

Conflict of interest
The author is an employee of Unilever plc.

Role of the funding source

Research funded by Unilever Oral Care.

references

1. Watts A, Addy M. Tooth discoloration and staining: a review

of the literature. British Dental Journal 2001;190:30916.
2. Joiner A. Tooth color: a review of the literature. Journal of
Dentistry 2004;32(Suppl. 1):312.
3. Ten Bosch JJ, Coops JC. Tooth color and reflectance as
related to light scattering and enamel hardness. Journal of
Dental Research 1995;74:37480.
4. Muia PJ. The four dimensional tooth color system. Chicago:
Quintessence Publishing Co., Inc.; 1985.
5. Joiner A, Jones NM, Raven SJ. Investigation of factors
influencing stain formation utilizing an in situ model.
Advances in Dental research 1995;9:4716.
6. Nathoo S. The chemistry and mechanisms of extrinsic and
intrinsic discoloration. Journal of the American Dental
Association 1997;128:6S10S.
7. Hannig M, Joiner A. The structure, function and properties
of the acquired pellicle. In: Duckworth RM, editor. The teeth
and their environment physical chemical and biochemical
influences Monographs in Oral Science, 1st ed., vol. 19. Basel:
Karger; 2006. p. 2964.
8. Brading MG, Joiner A, Kinane DF. Changes in oral health and
condition with age. International Dental Journal 2009;59:
30920.
9. Alkhatib MN, Holt R, Bedi R. Age and perception of dental
appearance and tooth color. Gerodontology 2005;22:326.
10. Xiao J, Zhou XD, Zhu WC, Zhang B, Li JY, Xu X. The
prevalence of tooth discoloration and the self-satisfaction
with tooth color in a Chinese urban population. Journal of
Oral Rehabilitation 2007;34:35160.
11. Alkhatib MN, Holt R, Bedi R. Prevalence of self-assessed
tooth discoloration in the United Kingdom. Journal of
Dentistry 2004;32:5616.
12. White DJ. Development of an improved whitening dentifrice
based upon stain-specific soft silica technology. Journal of
Clinical Dentistry 2001;12:259. Spec. Iss. 2.
13. Pickles MJ, Evans M, Philpotts CJ, Joiner A, Lynch RJM, Noel
N, et al. In vitro efficacy of a whitening toothpaste containing
calcium carbonate and perlite. International Dental Journal
2005;55:197202.
14. Joiner A. The bleaching of teeth: a review of the literature.
Journal of Dentistry 2006;34:4129.
15. Joiner A, The cleaning of teeth. Johansson I, Somasundaran
P, editors. Handbook for cleaning/decontamination of surfaces,
vol. 1. Basel: Karger; 2007. p. 371405.
16. Stookey GK, Barnhard TA, Schemehorn BR. In vitro removal
of stain with dentifrices. Journal of Dental Research
1982;61:12369.

17. Joiner A, Pickles MJ, Tanner C, Weader E, Doyle P. An in situ

model to study the toothpaste abrasion of enamel. Journal of
Clinical Periodontology 2004;31:4348.
18. Nordbo H. Discoloration of dental pellicle by tannic acid.
Acta Odontologica Scandinavica 1977;35:30510.
19. Rice DE, Dhabhar DJ, White DJ. Laboratory stain removal
and abrasion characteristics of a dentifrice based upon a
novel silica technology. Journal of Clinical Dentistry
2001;12:347.
20. Torrado A, Valiente M, Munoz CA. Cleaning power and
abrasivity of a new toothpaste based on ion-exchange
resins. American Journal of Dentistry 2004;17:804.
21. Wulknitz P. Cleaning power and abrasivity of European
toothpastes. Advances in Dental Research 1997;11:5769.
22. Lima DA, Silva AL, Agular FH, Liporoni PC, Munin E,
Ambrosano GM, et al. In vitro assessment of the
effectiveness of whitening dentifrices for the removal of
extrinsic stain. Brazilian Oral Research 2008;22:10611.
23. Dawson PL, Walsh JE, Morrison T, Grigor J. Dental stain
prevention by abrasive toothpastes: a new in vitro test and
its correlation with clinical observations. Journal of Cosmetic
Science 1998;49:27583.
24. Prayitno S, Addy M. An in vitro study of factors affecting the
development of staining associated with the use of
chlorhexidine. Journal of Periodontal Research 1979;14:397402.
25. Addy M, Goodfield S, Harrison A. The use of acrylic to
compare the abrasivity and stain removal properties of
toothpaste. Clinical Materials 1991;7:21925.
26. Sharif N, MacDonald E, Hughes J, Newcombe RG, Addy M.
The chemical stain removal properties of whitening
toothpaste products: studies in vitro. British Dental Journal
2000;188:6204.
27. Kleber CJ, Putt MS, Nelson BJ. In vitro tooth whitening by a
sodium bicarbonate/peroxide dentifrice. Journal of Clinical
Dentistry 1998;9:1621.
28. Kleber CJ, Moore MH, Nelson BJ. Laboratory assessment of
tooth whitening by sodium bicarbonate dentifrices. Journal
of Clinical Dentistry 1998;9:725.
29. Joiner A, Philpotts CJ, Alonso C, Ashcroft AT, Sygrove NJ. A
novel optical approach to achieving tooth whitening. Journal
of Dentistry 2008;36:S814.
30. Putt MS, Moore MH, Milleman JL, Milleman KR, Thong SH,
Vorwerk LM, et al. Clinical validation and calibration of in
vitro peroxide tooth whitening. Journal of Clinical Dentistry
2009;20:7986.
31. Collins LZ, Naeeni M, Schafer F, Brignoli C, Schiavi A,
Roberts J, et al. The effect of a calcium carbonate/perlite
toothpaste on the removal of extrinsic tooth stain in two
weeks. International Dental Journal 2005;55:17982.
32. Joiner A, Pickles MJ, Matheson JR, Weader E, Noblet L,
Huntington E. Whitening toothpastes: effects on tooth stain
and enamel. International Dental Journal 2002;52:42430.
33. Matheson JR, Cox TF, Baylor N, Joiner A, Patil R, Karad V,
et al. Effect of toothpaste with natural calcium carbonate/
perlite on extrinsic tooth stain. International Dental Journal
2004;55:3215.
34. Koertge TE, Brooks CN, Sarbin AG, Powers D, Gunsolley JC. A
longitudinal comparison of tooth whitening resulting from
dentifrice use. Journal of Clinical Dentistry 1998;9:6771.
35. Sielski C, Berta RL, Petrone ME, Chaknis P, De Vizio W, Volpe
AR, et al. A study to assess the tooth whitening efficacy of a
new dentifrice formulation variant containing a special
grade of silica: a six-week study on adults. Journal of Clinical
Dentistry 2002;13:7781.
36. Nathoo S, Singh S, Petrone DM, Wachs GN, Chaknis P,
De Vizio W, et al. Clinical studies to assess the extrinsic
stain prevention and stain removal efficacy of a variant
of a commercially available dentifrice containing a new

journal of dentistry 38s (2010) e17e24

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

dual silica system. Journal of Clinical Dentistry 2008;19:

95101.
Li YC, He T, Sun LL, Zhang YQ, Li X, Wang Y, et al. Extrinsic
stain removal efficacy of a dual-phase dentifrice. American
Journal of Dentistry 2007;20:22730.
He T, Baker R, Bartizek RD, Biesbrock AR, Chaves E,
Terezhalmy G. Extrinsic stain removal efficacy of a
stannous fluoride dentifrice with sodium
hexametaphosphate. Journal of Clinical Dentistry 2007;
18:711.
Soparkar P, Rustogi K, Zhang YP, Petrone ME, De Vizio W,
Proskin HM. Comparative tooth whitening and extrinsic
tooth stain removal efficacy of two tooth whitening
dentifrices: six-week clinical trial. Journal of Clinical Dentistry
2004;15:4651.
Gerlach RW, Liu H, Prater ME, Ramsey LL, White DJ. Removal
of extrinsic stain using a 7.0% sodium hexametaphosphate
dentifrice: a randomized clinical trial. Journal of Clinical
Dentistry 2002;13:69.
Gerlach RW, Ramsey LL, White DJ. Extrinsic stain removal
with a sodium hexametaphosphate-containing dentifrice:
comparisons to marketed controls. Journal of Clinical
Dentistry 2002;13:104.
Gerlach RW, White DJ. Removal of extrinsic stain using a
tartar control whitening dentifrice: a randomized clinical
trial. Journal of Clinical Dentistry 2001;12:426.
Ayad F, De Sciscio P, Stewart B, De Vizio W, Petrone ME,
Volpe AR. The stain prevention efficacy of two tooth
whitening dentifrices. Compendium of Continuing Education in
Dentistry 2002;23:7337.
Isaacs RL, Bartizek RD, Owens TS, Walters PA, Gerlach RW.
Maintenance of tooth color after prophylaxis: comparison of
three dentifrices. Journal of Clinical Dentistry 2001;12:515.
Sharma N, Galustians HJ, Qaqish J, Rustogi K, Zhang YP,
Petrone ME, et al. Comparative tooth whitening and extrinsic
tooth stain prevention efficacy of a new dentifrice and a
commercially available tooth whitening dentifrice: six-week
clinical trial. Journal of Clinical Dentistry 2004;15:527.
Claydon NCA, Moran J, Bosma ML, Shirodaria S, Addy M,
Newcombe R. Clinical study to compare the effectiveness of
a test whitening toothpaste with a commercial whitening
toothpaste at inhibiting dental stain. Journal of Clinical
Periodontology 2004;31:108891.
Gerlach RW, Ramsey LL, Baker RA, White DJ. Extrinsic stain
prevention with a combination dentifrice containing
calcium phosphate surface active builders compared to two
marketed controls. Journal of Clinical Dentistry 2001;13:158.
Tillis TSI. Use of a whitening dentifrice for control of
chlorhexidine stain. Journal of Contemporary Dental Practice
1999;1:19.
Lobene RR. Effect of dentifrices on tooth stains with
controlled brushing. Journal of the American Dental Association
1968;77:84955.
Macpherson LMD, Stephen KW, Joiner A, Schafer F,
Huntington E. Comparison of a conventional and modified
tooth stain index. Journal of Clinical Periodontology
2000;27:8549.
Shaw L, Murray JJ. A new index for measuring stain in
clinical trials. Community Dentistry and Oral Epidemiology
1977;5:11620.
Davis WB, Rees DA. A parametric test to measure the
cleaning power of toothpaste. Journal of the Society of Cosmetic
Chemistry 1975;26:21755.
Kakar A, Rustogi K, Zhang YP, Petrone ME, De Vizio W,
Proskin HM. A clinical investigation of the tooth whitening
efficacy of a new hydrogen peroxide-containing dentifrice.
Journal of Clinical Dentistry 2004;15:415.
Walsh TF, Rawlinson A, Wildgoose D, Marlow I, Haywood J,
Ward JM. Clinical evaluation of the stain removing ability of

55.

56.

57.

58.

59.

60.
61.
62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

e23

a whitening dentifrice and stain controlling system. Journal

of Dentistry 2005;33:4138.
Niwa M, Sato T, Li W, Aoki H, Aoki H, Daisaku T. Polishing
and whitening properties of toothpaste containing
hydroxyapatite. Journal of Materials Science Materials in
Medicine 2001;12:27781.
Gerlach RW, Barker ML. Clinical response of three direct-toconsumer whitening products: strips, paint-on gel, and
dentifrice. Compendium of Continuing Education in Dentistry
2003;24:45864.
Collins LZ, Naeeni M, Platten SM. Instant tooth whitening
from a silica toothpaste containing blue covarine. Journal of
Dentistry 2008;36:S215.
Gerlach RW, Barker ML, Tucker HL. Clinical response of
three whitening products having different peroxide
delivery: comparison of tray, paint-on, and dentifrice.
Journal of Clinical Dentistry 2004;15:1127.
Yudhira R, Peumans M, Barker ML, Gerlach RW. Clinical trial
of tooth whitening with 6% hydrogen peroxide whitening
strips and two whitening dentifrices. American Journal of
Dentistry 2007;20:32A6A.
Forward GC. Role of toothpastes in the cleaning of teeth.
International Dental Journal 1991;41:16470.
Hefferren JJ. Historical view of dentifrice functionality
methods. Journal of Clinical Dentistry 1998;9:536.
Lewis R, Dwyer-Joyce RS, Pickles MJ. Interaction between
toothbrushes and toothpaste abrasive particles in simulated
tooth cleaning. Wear 2004;257:36876.
Davis WB, The cleaning, polishing and abrasion of teeth by
dental products. Breuer MM, editor. Cosmetic science, vol. 1.
London: Academic Press; 1978. p. 3981.
De Boer P, Duinkerke ASH, Arends J. Influence of tooth paste
particle size and tooth brush stiffness on dentine abrasion
in vitro. Caries Research 1985;19:2329.
Harte DB, Manly RS. Four variables affecting magnitude of
dentifrice abrasiveness. Journal of Dental Research
1976;55:3227.
Hunter ML, Addy M, Pickles MJ, Joiner A. The role of
toothpastes and toothbrushes in the aetiology of tooth
wear. International Dental Journal 2002;52:399405.
Pickles MJ, Tooth wear. Duckworth RM, editor. The teeth and
their environment Monographs in oral science, vol. 19. Basel:
Karger; 2006. p. 86104.
Lewis R, Dwyer-Joyce RS. Wear of human teeth: a
tribological perspective. Proceedings IMechE Part J Engineering
Tribology 2005;219:118.
Hefferren JJ. A laboratory method for assessment of
dentifrice abrasivity. Journal of Dental Research 1976;55:
56373.
Singh S, Mankodi S, Chaknis P, Petrone ME, De Vizio W,
Volpe AR, et al. The clinical efficacy of a new tooth
whitening dentifrice formulation: a six-month study in
adults. Journal of Clinical Dentistry 2002;13:8690.
Ayad F, Khalaf A, Chaknis P, Petrone ME, De Vizio W, Volpe
AR, et al. Clinical efficacy of a new tooth whitening
dentifrice. Journal of Clinical Dentistry 2002;13:825.
Nathoo S, Petrone ME, De Vizio W, Chaknis P, Volpe AR. A
six-week clinical study to compare the stain removal
efficacy of three dentifrices. Journal of Clinical Dentistry
2002;13:914.
Sreenivasan P, De Vizio W, Prasad KVV, Rajesh G, Kalyanpur
R, Bhasker Rao C. Clinical stain removal efficacy of two
dentifrices after one and two weeks of use. Journal of Clinical
Dentistry 2009;20:22730.
Joiner A, Weader E, Cox TF. The measurement of enamel
wear of two toothpastes. Oral Health and Preventative
Dentistry 2004;2:3838.
Joiner A, Collins LZ, Cox TF, Pickles MJ, Weader E,
Liscombe C, et al. The measurement of enamel and

e24

76.

77.

78.

79.

80.

81.

82.

83.

84.

85.

86.

journal of dentistry 38s (2010) e17e24

dentine abrasion by tooth whitening products

using an in situ model. International Dental Journal
2005;55:1946.
Joiner A. Review of the extrinsic stain removal and enamel/
dentine abrasion by a calcium carbonate and perlite
containing whitening toothpaste. International Dental Journal
2006;56:17580.
Baig A, He T, Buisson J, Sagel L, Suszcynsky-Meister E,
White DJ. Extrinsic whitening effects of sodium
hexametaphosphatea review including a dentifrice
with stabilized stannous fluoride. Compendium in Continuing
Education in Dentistry 2005;26(Suppl. 1):4753.
Pontefract H, Sheen S, Addy M. The benefits of toothpaste
real or imagined? Review of its role in tooth whitening.
Dental Update 2001:6774.
Hoic D, Dixit N, Prencipe M, Subramanyam R, Cameron R,
Malak RA, et al. The technology behind Colgate Simply
White toothpaste. Journal of Clinical Dentistry 2004;15:3740.
Ayad F, Arcuri H, Brevilieri E, Laffi S, Lemos AM, Yoshioka M,
et al. Efficacy of two dentifrices on removal of natural
extrinsic stain. American Journal of Dentistry 1999;12:1646.
Harrison JWE, Salisbury GB, Abbott DD. Effect of enzymetoothpastes upon oral hygiene. Journal of Periodontology
1963;34:3347.
Norbo H, Pulkkanen U, Eriksen HM, Enersen M. The capacity
of a new dentifrice to prevent and remove extrinsic
discoloration. Clinical Preventive Dentistry 1988;10:157.
Emling RC, Levin S, Shi X, Weinberg S, Yankell SL.
Rembrandt toothpaste stain prevention with and without
the use of Peridex. Journal of Clinical Dentistry 1992;3:5965.
Lyon TC, Parker WA, Barnes GP. Evaluation of effects of
application of a citroxain-containing dentifrice. Journal of
Esthetic Dentistry 1991;3:513.
Emling RC, Shi X, Yankell SL. Rembrandt toothpaste: stain
removal following the use of Peridex. Journal of Clinical
Dentistry 1992;3:669.
White DJ. A new and improved dual action whitening
dentifrice technologysodium hexametaphosphate. Journal
of Clinical Dentistry 2002;13:18. Spec. Iss. 1.

87. Shellis RP, Addy M, Rees GD. In vitro studies on the effect of
sodium tripolyphosphate on the interactions of stain and
salivary protein with hydroxyapatite. Journal of Dentistry
2005;33:31324.
88. Mankodi S, Sowinski J, Davies R, Ellwood R, Bradshaw B,
Petrone ME, et al. A six-week clinical efficacy study of a
tooth whitening tartar control dentifrice for the removal
of extrinsic tooth stain. Journal of Clinical Dentistry
1999;10:99102.
89. Ayad F, Demarchi B, Khalaf A, Petrone ME, Chaknis P, De
Vizio W, et al. A six-week clinical efficacy study of a new
dentifrice for the removal of extrinsic tooth stain. Journal of
Clinical Dentistry 1999;10:1036.
90. Ayad F, Demarchi B, Khalaf A, Davies R, Ellwood R,
Bradshaw B, et al. A six-week clinical tooth whitening study
of a new calculus-inhibiting dentifrice formulation. Journal
of Clinical Dentistry 2000;11:847.
91. Baig AA, Kozak KM, Cox ER, Zoladz JR, Mahony L, White DJ.
Laboratory studies on the chemical whitening effects of a
sodium hexametaphosphate dentifrice. Journal of Clinical
Dentistry 2002;13:1924.
92. Terezhalmy G, Chaves E, Bsoul S, Baker R, He T. Clinical
evaluation of the stain removal efficacy of a novel stannous
fluoride and sodium hexametaphosphate dentifrice.
American Journal of Dentistry 2007;20:538.
93. Terezhalmy G, Biesbrock AR, Farrell S, Barker ML, Bartizek
RD. Tooth whitening through the removal of extrinsic stain
with two sodium hexametaphosphate-containing
whitening dentifrices. American Journal of Dentistry
2007;20:30914.
94. Joiner A, Hopkinson I, Deng Y, Westland S. A review of tooth
color and whiteness. Journal of Dentistry 2008;36:S27.
95. Joiner A. A silica toothpaste containing blue covarine: a new
technological breakthrough in whitening. International
Dental Journal 2009;59:2848.
96. Joiner A, Philpotts CJ, Ashcroft AT, Laucello M, Salvaderi A.
In vitro cleaning, abrasion and fluoride efficacy of a new
silica based whitening toothpaste containing blue covarine.
Journal of Dentistry 2008;36:S3237.