Non-Cochrane · intervention · PM42936803
Efficacy and safety of internal bleaching agents for discolored endodontically treated teeth: A systematic review and network meta-analysis of in vitro and ex vivo studies.
Drouri Sofia, Essanhajy Zohair, Jabri Mouna · Journal of conservative dentistry and endodontics · 2026 · PubMed · doi:10.4103/jcde.jcde_776_26
Findings
96 findings
| Population | ||||
|---|---|---|---|---|
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Santos (2020) omitted | SMD 3.60 [2.37, 4.83] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, El Zayat (2025) omitted | SMD 2.92 [1.49, 4.34] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Feiz (2014) omitted | SMD 2.70 [1.10, 4.30] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Majidinia (2025) omitted | SMD 2.89 [1.50, 4.28] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Arslan (2025) omitted | SMD 2.66 [1.22, 4.10] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | CP | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD 2.66 [1.31, 4.01] GRADE not reported 3 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 2.90 [1.61, 4.20] Low Downgraded: risk of bias, imprecision, inconsistency 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: no-outlier network | SMD 2.91 [1.57, 4.26] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | CP | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD 5.83 [1.11, 10.54] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Yogha-Padhma (2018) omitted | SMD 2.90 [1.61, 4.20] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Papadopoulos (2021) omitted | SMD 2.91 [1.57, 4.26] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | CP | Control | Immediate color change End of active bleaching · Laboratory · Human teeth only | SMD 3.50 [1.96, 5.04] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 3.05 [1.94, 4.17] GRADE not reported 9 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, de Almeida b (2023) omitted | SMD 2.61 [1.24, 3.98] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | HP + activation | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD 1.88 [-0.07, 3.82] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Santos (2020) omitted | SMD 3.48 [2.21, 4.74] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 2.74 [1.46, 4.01] GRADE not reported 9 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: no-outlier network | SMD 2.55 [0.93, 4.17] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Feiz (2014) omitted | SMD 2.52 [0.93, 4.11] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Papadopoulos (2021) omitted | SMD 2.55 [0.93, 4.17] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Yogha-Padhma (2018) omitted | SMD 2.64 [1.14, 4.13] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | HP + activation | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD 3.72 [1.40, 6.04] GRADE not reported 1 study |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, El Zayat (2025) omitted | SMD 2.61 [0.86, 4.35] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 2.64 [1.14, 4.13] Very low Downgraded: risk of bias, imprecision, inconsistency, indirectness 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Majidinia (2025) omitted | SMD 2.85 [1.16, 4.55] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, de Almeida b (2023) omitted | SMD 1.85 [-0.13, 3.84] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | HP + activation | Control | Immediate color change End of active bleaching · Laboratory · Human teeth only | SMD 3.57 [1.24, 5.90] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Arslan (2025) omitted | SMD 2.40 [0.92, 3.89] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Papadopoulos (2021) omitted | SMD 2.07 [0.75, 3.39] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Santos (2020) omitted | SMD 2.01 [0.84, 3.17] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | SP/perborate | Control | Immediate color change End of active bleaching · Laboratory · Human teeth only | SMD 1.91 [0.44, 3.38] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Arslan (2025) omitted | SMD 2.71 [1.29, 4.13] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 2.06 [0.79, 3.33] Low Downgraded: risk of bias, imprecision, inconsistency 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Majidinia (2025) omitted | SMD 2.05 [0.68, 3.42] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, El Zayat (2025) omitted | SMD 2.07 [0.67, 3.48] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Yogha-Padhma (2018) omitted | SMD 2.06 [0.79, 3.33] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Feiz (2014) omitted | SMD 1.71 [0.12, 3.29] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: no-outlier network | SMD 2.07 [0.75, 3.39] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | SP/perborate | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD 5.74 [0.99, 10.50] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 1.27 [0.06, 2.48] GRADE not reported 9 studies |
| Discolored endodontically treated or simulated teeth | SP/perborate | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD 1.78 [0.46, 3.09] GRADE not reported 3 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate (SP/perborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, de Almeida b (2023) omitted | SMD 1.78 [0.44, 3.12] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: no-outlier network | SMD 2.06 [0.78, 3.35] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | HP | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD 3.16 [-0.28, 6.60] GRADE not reported Studies not reported |
| Discolored endodontically treated or simulated teeth | HP | Control | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD 1.87 [0.56, 3.19] GRADE not reported 3 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Yogha-Padhma (2018) omitted | SMD 2.04 [0.81, 3.27] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Papadopoulos (2021) omitted | SMD 2.06 [0.78, 3.35] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Arslan (2025) omitted | SMD 1.79 [0.45, 3.13] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Feiz (2014) omitted | SMD 1.90 [0.57, 3.24] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 2.10 [1.04, 3.15] GRADE not reported 9 studies |
| Discolored endodontically treated or simulated teeth | HP | Control | Immediate color change End of active bleaching · Laboratory · Human teeth only | SMD 2.70 [0.84, 4.56] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Santos (2020) omitted | SMD 3.02 [1.89, 4.16] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 2.04 [0.81, 3.27] Low Downgraded: risk of bias, imprecision, inconsistency 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, de Almeida b (2023) omitted | SMD 1.34 [-0.20, 2.88] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, El Zayat (2025) omitted | SMD 2.06 [0.69, 3.42] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Majidinia (2025) omitted | SMD 2.00 [0.67, 3.33] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Santos (2020) omitted | SMD 1.72 [-0.33, 3.76] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: no-outlier network | SMD 1.78 [-0.88, 4.44] GRADE not reported 7 studies |
| Discolored endodontically treated or simulated teeth | Other agent | Control | Immediate color change End of active bleaching · Laboratory · Human teeth only | SMD 1.62 [-0.90, 4.14] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 0.98 [-1.25, 3.21] GRADE not reported 9 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Feiz (2014) omitted | SMD 1.42 [-1.40, 4.23] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Papadopoulos (2021) omitted | SMD 1.78 [-0.88, 4.44] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, de Almeida b (2023) omitted | SMD 1.49 [-1.14, 4.13] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Majidinia (2025) omitted | SMD 1.76 [-1.00, 4.52] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, Arslan (2025) omitted | SMD 2.42 [0.00, 4.84] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 1.77 [-0.79, 4.33] Very low Downgraded: risk of bias, imprecision, indirectness 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Sensitivity: leave-one-out, El Zayat (2025) omitted | SMD 1.78 [-1.06, 4.62] GRADE not reported 7 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Hydrogen peroxide (HP) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 0.86 [-0.52, 2.25] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 0.27 [-1.40, 1.94] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Other agent (sodium tetraborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 1.13 [-1.43, 3.69] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Carbamide peroxide (CP) | Sodium perborate (SP/perborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 0.84 [-0.43, 2.11] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD -0.60 [-1.64, 0.45] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Other agent (sodium tetraborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 0.27 [-2.35, 2.88] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide (HP) | Sodium perborate (SP/perborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD -0.02 [-1.40, 1.36] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Other agent (sodium tetraborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 0.86 [-1.91, 3.64] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide with physical activation (laser/LED/ultrasonic) (HP + activation) | Sodium perborate (SP/perborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD 0.58 [-1.09, 2.24] GRADE not reported 8 studies · 354 participants |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Other agent (sodium tetraborate) | Sodium perborate (SP/perborate) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory | SMD -0.29 [-2.51, 1.93] GRADE not reported 8 studies · 354 participants |
| Discolored endodontically treated or simulated teeth | CP | HP | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD 1.24 [-0.32, 2.80] GRADE not reported 2 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate + carbamide peroxide (SP + CP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 3.35 [1.83, 4.87] GRADE not reported 9 studies |
| Discolored endodontically treated or simulated teeth | CP | HP | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD -0.57 [-3.59, 2.45] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Sodium perborate + hydrogen peroxide (SP + HP) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 3.22 [1.52, 4.92] GRADE not reported 9 studies |
| Discolored endodontically treated or simulated teeth | CP | SP/perborate | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD -8.72 [-52.27, 34.83] GRADE not reported Studies not reported |
| Discolored endodontically treated or simulated teeth | CP | SP/perborate | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD 0.85 [-0.42, 2.12] GRADE not reported 3 studies |
| Discolored endodontically treated or simulated teeth | HP | HP + activation | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD -4.51 [-9.46, 0.45] GRADE not reported Studies not reported |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide + calcium oxalate (HP + Ca-oxalate) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 3.07 [1.19, 4.95] GRADE not reported 9 studies |
| Discolored endodontically treated or simulated teeth | HP | HP + activation | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD -0.41 [-1.48, 0.66] GRADE not reported 4 studies |
| Discolored endodontically treated or simulated teeth | HP | SP/perborate | Immediate color change End of active bleaching · Laboratory · Node splitting: Indirect estimate | SMD 0.56 [-2.37, 3.49] GRADE not reported Studies not reported |
| Discolored endodontically treated or simulated teeth | HP | SP/perborate | Immediate color change End of active bleaching · Laboratory · Node splitting: Direct estimate | SMD -0.19 [-1.75, 1.38] GRADE not reported 2 studies |
| Extracted permanent teeth, endodontically treated or simulated, with intrinsic or experimentally induced discoloration | Hydrogen peroxide + calcium oxalate + activation (HP + Ca-oxalate + activation) | Untreated control (no bleaching) | Immediate color change (standardized across ΔEab/ΔE00 metrics) Immediate (end of active bleaching) · In vitro / ex vivo laboratory · Exploratory fine (disaggregated) network, 10 nodes | SMD 2.85 [0.98, 4.73] GRADE not reported 9 studies |
| Discolored endodontically treated or simulated teeth | Control | Baseline color | Color change ΔEab End of active bleaching · Laboratory · Random-effects pooled arm mean | MEAN 3.34 [2.89, 3.80] GRADE not reported 3 studies |
| Discolored endodontically treated or simulated teeth | CP | Baseline color | Color change ΔEab End of active bleaching · Laboratory · Random-effects pooled arm mean | MEAN 11.38 [9.77, 13.00] GRADE not reported 2 studies |
| Discolored endodontically treated or simulated teeth | HP | Baseline color | Color change ΔEab End of active bleaching · Laboratory · Random-effects pooled arm mean | MEAN 15.79 [1.50, 30.07] GRADE not reported 4 studies |
| Discolored endodontically treated or simulated teeth | HP | Baseline color | Color change ΔE00 End of active bleaching · Laboratory · Random-effects pooled arm mean | MEAN 17.25 [6.58, 27.92] GRADE not reported 2 studies |
| Discolored endodontically treated or simulated teeth | HP + activation | Baseline color | Color change ΔEab End of active bleaching · Laboratory · Random-effects pooled arm mean | MEAN 21.28 [-0.60, 43.16] GRADE not reported 3 studies |
| Discolored endodontically treated or simulated teeth | SP/perborate | Baseline color | Color change ΔEab End of active bleaching · Laboratory · Random-effects pooled arm mean | MEAN 16.46 [8.79, 24.14] GRADE not reported 3 studies |
| Discolored endodontically treated or simulated teeth | Internal bleaching agents | Alternative agents or no bleaching | External cervical root resorption Laboratory | no estimate extracted No studies found 0 studies |
Included primary studies 26
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Arslan 2025 Comparative study of the effectiveness of different bleaching agents on blood-colored extracted teeth and investigation of recoloring… PMID:40660936 | 2025 | this review only | not stated | not extracted yet |
| Cardoso 2013 Ultrasonic activation of internal bleaching agents. PMID:22788541 | 2013 | this review only | not stated | not extracted yet |
| Celik 2019 Deionized water can substitute common bleaching agents for nonvital tooth bleaching when treated with non-thermal atmospheric plasma. PMID:30713266 | 2019 | this review only | not stated | not extracted yet |
| Coppola 2023 Chemical, morphological and microhardness analysis of coronary dentin submitted to internal bleaching with hydrogen peroxide and violet LED. PMID:37890812 | 2023 | this review only | not stated | not extracted yet |
| Daneshpooy 2024 Investigating the Effect of Internal Bleaching With 10% Carbamide Peroxide on the Color Change of Three Types of Common Endodontic Sealers. PMID:38420069 | 2024 | this review only | not stated | not extracted yet |
| de Almeida 2023a Effectiveness and color stability of non-vital dental bleaching photoactivated by violet LED on blood-stained teeth. PMID:36758735 | 2023 | this review only | not stated | not extracted yet |
| de Almeida 2023b Effect of non-vital tooth bleaching photoactivated with blue or violet LED on color and microhardness. PMID:37037401 | 2023 | this review only | not stated | not extracted yet |
| de Almeida 2023c Fracture strength and hybrid layer formation of endodontically-treated teeth after dental bleaching photoactivated with violet LED. PMID:37748699 | 2023 | this review only | not stated | not extracted yet |
| El Zayat 2025 The Effect of Novel Laser-Activated Bleaching Protocols on the Color Change of Non-Vital Anterior Teeth: An In Vitro Study. PMID:39750516 | 2025 | this review only | not stated | not extracted yet |
| Feiz 2014 Effect of several bleaching agents on teeth stained with a resin-based sealer. PMID:23647234 | 2014 | this review only | not stated | not extracted yet |
| Gaidarji 2022 Effectiveness and color stability of bleaching techniques on blood-stained teeth: An in vitro study. PMID:34859941 | 2022 | this review only | not stated | not extracted yet |
| Jang 2013 Tooth discoloration after the use of new pozzolan cement (Endocem) and mineral trioxide aggregate and the effects of internal bleaching. PMID:24238455 | 2013 | this review only | not stated | not extracted yet |
| Kaneko 2000 Bleaching effect of sodium percarbonate on discolored pulpless teeth in vitro. PMID:11194360 | 2000 | this review only | not stated | not extracted yet |
| Majidinia 2025 Internal bleaching with calcium oxalate and laser irradiation for managing discolorations induced by mineral trioxide aggregate. PMID:40055702 | 2025 | this review only | not stated | not extracted yet |
| Marchesan 2018 Effect of access design on intracoronal bleaching of endodontically treated teeth: An ex vivo study. PMID:28858418 | 2018 | this review only | not stated | not extracted yet |
| Martin-Biedma 2010 Colorimeter and scanning electron microscopy analysis of teeth submitted to internal bleaching. PMID:20113803 | 2010 | this review only | not stated | not extracted yet |
| Papadopoulos 2021 Spectrophotometric evaluation of the effectiveness of Er,Cr:YSGG laser-assisted intracoronal tooth bleaching treatment using different… PMID:33798751 | 2021 | this review only | not stated | not extracted yet |
| Salem 2022 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Santos 2020 [Hip pain in children]. PMID:2020816 | 1991 | this review only | not stated | not extracted yet |
| Tavsan 2025 Effects of non-vital bleaching agents and resin composites on the color stability, translucency, and whiteness index of stained teeth at… PMID:40611161 | 2025 | this review only | not stated | not extracted yet |
| Teodosio 2022 Bleaching effect of violet LED of 405-410 nm on stained endodontically treated teeth. PMID:35644346 | 2022 | this review only | not stated | not extracted yet |
| Wang 2018 A colourimetric evaluation of the effect of bacterial contamination on teeth stained with blood in vitro: Evaluation of the efficacy of… PMID:29485695 | 2018 | this review only | not stated | not extracted yet |
| Wei 2016 Spectroradiometric and Chemical Analysis of Severely Discolored Endodontically Treated Teeth. PMID:26919085 | 2016 | this review only | not stated | not extracted yet |
| Yang 2021 Tooth discoloration and the effects of internal bleaching on the novel endodontic filling material SavDen® MTA. PMID:32600866 | 2021 | this review only | not stated | not extracted yet |
| Yogha-Padhma 2018 Tooth discoloration and internal bleaching after the use of ledermix paste with various bleaching agents - An in vitro study. PMID:30607221 | 2018 | this review only | not stated | not extracted yet |
| Yui 2008 Ex vivo evaluation of the effectiveness of bleaching agents on the shade alteration of blood-stained teeth. PMID:18422585 | 2008 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Extracted permanent teeth, endodontically treated or experimentally prepared to simulate endodontically treated teeth, with intrinsic or experimentally induced discoloration relevant to nonvital teeth | Extracted human anterior teeth (most), bovine specimens (4), one intact human tooth; discoloration mostly blood-induced, also sealer, tetracycline, tea, coffee, red wine, MTA/restorative materials (n=26 reports, 24 studies) |
| Intervention | Internal bleaching: walking-bleach, in-office intracoronal, inside-outside, and chemically or physically activated protocols (agent nodes defined a priori by bleaching agent and activation) | SP, HP, CP at various concentrations alone or combined; activation with diode or Er,Cr:YSGG lasers, blue/violet LEDs, nonthermal plasma, ultrasonic; calcium oxalate; sodium tetraborate; sodium percarbonate (primary network: CP, HP, HP + activation, SP/perborate, other agent; n=8 studies) |
| Comparison | Baseline color, no bleaching, placebo or distilled/deionized water, or an alternative agent, concentration, technique, activation method, or time point | Untreated control and alternative agents/activation (primary network reference: untreated control) |
| Outcomes | Primary: immediate color change (ΔEab, ΔE00, WID, CIELAB coordinates; visual shade guide separately). Secondary: color stability/relapse/recoloration; dentine or enamel microhardness; fracture resistance; surface morphology, tubule exposure, chemical change or roughness; bond strength and resin-dentine interface integrity; cervical sealing or leakage | Immediate color change pooled in NMA (n=8 studies, 354 specimen observations); color stability narrative (n=7 reports); structural, chemical, mechanical, restorative effects narrative (n=8 datasets); external cervical resorption not measured (n=0) |
| Study designs | In vitro and ex vivo laboratory studies only | In vitro and ex vivo laboratory studies (n=26 reports) |
| Timing | Immediate efficacy at end of active bleaching; longest available time point for stability | Follow-up from a single measurement to 9 months |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Yes | Partial Yes | no |
| 3Choice of study designs explained | Yes | Yes | yes |
| 4Comprehensive literature searchcritical | No | Partial Yes | no |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Yes | Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: N/A · NRSI: Partial Yes | NRSI: N/A · RCT: N/A | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: N/A · NRSI: Yes | NRSI: N/A · RCT: N/A | no |
| 12Impact of risk of bias on the pooled results | Yes | Yes | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | Yes | Yes | yes |
| 16Conflicts of interest reported | Yes | Partial Yes | no |
| Overall | Critically Low | Low | no |