DOI: 10.4103/jcde.jcde_776_26 ISSN: 2950-4716

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

Sofia Drouri, Zohair Essanhajy, Mouna Jabri
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Abstract

Background:

Discoloration of endodontically treated teeth is a common esthetic problem, and internal bleaching is its most conservative treatment. Laboratory evidence comparing agents and activation methods is fragmented.

Aims:

To synthesize in vitro and ex vivo evidence and to compare, rank, and appraise the immediate color-change efficacy of internal-bleaching agents and activation approaches and to summarize color stability and structural effects.

Materials and Methods:

Following a PROSPERO-registered protocol (CRD420261277168) and PRISMA 2020, four databases (MEDLINE, Scopus, Web of Science, and CENTRAL) were searched up to 10 June 2026. In vitro and ex vivo studies of internal bleaching of discolored nonvital teeth were included. Risk of bias was assessed with the QUIN tool. A frequentist random-effects network meta-analysis expressed color change as the standardized mean difference (SMD) versus control; treatments were ranked by P-score and certainty appraised with GRADE.

Results:

Twenty-six reports were included; the primary network comprised eight studies. Every peroxide node produced significantly greater color change than control: carbamide peroxide (CP) SMD 2.90 (95% confidence interval: 1.61–4.20), activated hydrogen peroxide (HP) 2.64 (1.14–4.13), sodium perborate 2.06 (0.79–3.33), and HP 2.04 (0.81–3.27). No active agent was superior to another; CP ranked highest (P-score 0.844). Heterogeneity was high and certainty low to very low.

Conclusions:

All peroxide-based internal-bleaching agents effectively lighten nonvital teeth with no clear superiority among them; because efficacy is comparable, agent choice should also weigh effects on dental hard tissue.

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