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Teeth Whitening from A to Z: With a number of options available to patients, dental assistants can advise patients on the best choice for their care and their budget.

Teeth whitening has become one of the most popular esthetic dental procedures over the last two decades. (1) Teeth whitening is not a new procedure to dentistry. In fact, it has been around since the mid-to late 1800s, starting as in-office bleaching procedure to treat isolated, non-vital teeth darkened due to trauma or endodontic procedures. (1) It wasn't until the late 1980s that whitening products became available to treat vital teeth for overall teeth whitening. At that time, the most common whitening products available were dentist-prescribed in-office and at-home whitening systems. Today, many forms of whitening products are available.

As result of the popularity of teeth-whitening products, the American Dental Association (ADA) Council on Scientific Affairs began monitoring the development and increasing number of products that have become available on the market. (2) As dental professionals, it is important to understand whitening materials, indications for use, precautions, contraindications, the adverse effects of teeth whitening, and the options available for patients.

Whitening Materials

Because the market for whitening products has grown so much, the ADA recognized a need to make uniform definitions when discussing whiteners. Teeth whitening is any process that will make the teeth appear whiter. According to the ADA, this can be achieved two ways: using non-bleaching products and using bleaching products. Bleaching products change the natural tooth color by using peroxide, which helps remove deep (intrinsic) and surface (extrinsic) stains, whereas non-bleaching products work by using physical or chemical action that remove surface stains only. (2)

Bleaching products work by penetrating the tubules of the tooth enamel and dentin to oxidize the chromogens, which are dark or color compounds within the tooth. Oxidation occurs when the oxygen molecules from the whitening agents react with the discolored compounds and break the bonds that hold them together. After this reaction occurs, the chromogens become lighter colored compounds, resulting in a whiter tooth appearance. (3)

Non-bleaching products work by removing surface stains from the tooth enamel with the use of gentle polishing, chemical chelation, or some other non-bleaching actions.

Most teeth whitening products available today are made from peroxide-based ingredients that are supplied in different concentrations. The most common active ingredients to whiten teeth in the United States contain carbamide peroxide or hydrogen peroxide.' It is important to note that when carbamide peroxide decomposes or breaks down, it releases hydrogen peroxide and urea in an aqueous medium, resulting in a lesser amount of hydrogen peroxide utilized in the whitening process than when hydrogen peroxide is an active ingredient. For example, a 10 percent carbamide peroxide whitening treatment is equivalent to 3.5 percent hydrogen peroxide. (1)

Managing Patient Expectations

The indications for having the tooth whitening procedure are:

* Extrinsic stains from foods, cigarette smoking, coffee, wine, etc.

* Aged teeth (where the aged enamel naturally thins out, allowing the more yellow dentin to show through)

* Intrinsic stains, such as mild tetracycline (antibiotic) stains and mild fluorosis (from excessive fluoride)

A consultation is always recommended prior to whitening to ensure a patient doesn't have any underlying oral health issues. The ADA recommends that patients only choose a bleaching product after a consultation and thorough oral examination performed by a dentist. (2) This is especially important for patients with many fillings, crowns, and dark stains to determine if bleaching is an appropriate course of treatment and to meet the expectations of the patient. Moreover, it is recommended to treat existing issues before whitening treatment for those patients that may have periodontal disease, exhibit failing restorations, or otherwise unhealthy oral states.

During the consultation prior to whitening, it is important to explain to the patient that the results of tooth whitening can vary from patient to patient and are not permanent. Most patients can expect between six to eight shades lighter on the VITA Classical Shade Guide, depending on the type of stain, age of the patient, concentration of the whitening agent, and time and frequency of the whitening treatment. (1) For some patients, the results can be dramatic; for others, the results can be subtle and require additional time in treatment. In general, teeth with yellow or brown stains will achieve the greatest amount of success, while those with blue to gray shading resulting from tetracycline or medications may experience less dramatic results, though they should still notice improvement. Most whitening results last approximately three to five years, depending on the diet and the habits of the patients following whitening. (4)

During the consultation, it is important to explain to the patient that permanent restorations such as crowns, veneers, and composite restorations will not whiten and may require replacement following the whitening procedure to match whitened teeth. If a patient is diagnosed or elects to have permanent restorations to anterior teeth, ask the patient if he or she is interested in teeth whitening prior to selecting the shade for a crown, bridge, veneer, or composite restoration, providing the patient the opportunity to whiten their teeth first so that the new restoration matches.

Adverse Effects and Contraindications

When manufacturers' instructions are followed, hydrogen peroxide and carbamide peroxide teeth whitening products are safe and effective. However, patients should be informed on the risks or adverse effects of tooth whitening prior to the procedure. (3)

The most common adverse effects of teeth whitening are thermal hypersensitivity and gingival irritation'. The degree of each depends on the concentration of peroxide, duration of the whitening treatment, and the non-bleach component used. Thermal hypersensitivity is defined as hot and cold tooth sensitivity that can last up to several days and usually occurs immediately following tooth whitening treatment. Gingival irritation occurs within the first day of the treatment and can last up to several days. Gingival irritation occurs when the bleaching agent settles on the gingival tissues and is not removed during the whitening treatment. This can occur from an improper fitting whitening tray or if a patient overfills the whitening tray whereby the whitening agent can ooze onto the gingival tissues. (4)

Studies report that tooth whitening is a relatively safe procedure; however, researchers continue to study the adverse effects of bleaching on hard tissue, soft tissue, and restorative materials under conditions where consumers are likely to abuse a whitening product. (2) Abuse of teeth whitening products typically occurs with at-home and over-the-counter whitening products when a patent overuses a whitening product, or does not follow the manufacturer's instructions or the directions of the dental professional. (4) According to in-vitro studies, the risk associated with teeth whitening include tooth erosion, tooth mineral degradation, increased susceptibility to demineralization, and pulpal damage. (3) Other studies suggest that aggressive tooth bleaching can cause restoration changes by chemically reacting and reducing the stability of composite restorations, glass ionomer cements, sealants, and ceramic crowns3. It is important to note the rate the of adverse effects is unclear since most teeth whitening issues are not reported through the U.S. Food and Drug Administration (FDA) Medwatch system. (2) The ADA recommends that patients consult with a dentist before whitening to determine the most appropriate method to minimize the adverse effects of teeth whitening.

To help reduce tooth sensitivity during teeth whitening, some professional teeth whitening products are now made with potassium nitrate and fluoride or used alone with custom-made whitening trays. Potassium nitrate helps relieve tooth sensitivity quickly and provides comfort that lasts approximately 24 hours.' It works by entering the tubules of the enamel and dentin and traveling to the pulp of the tooth, where it has a calming effect on the pulp. Fluoride works by increasing the hardness of the enamel, which provides lasting relief from sensitivity. According to a study, a 10 percent carbamide peroxide bleaching gel containing potassium nitrate and fluoride produced less tooth sensitivity than a regular whitening system without potassium nitrate and fluoride during a 2-week at-home bleaching treatment. (6) Another study concluded that 5 percent potassium nitrate-fluoride used alone in custom trays can reduce sensitivity in a majority of patients and allows most patients to continue bleaching to completion. (7)

Research has not determined the possible other health-related effects of whitening, but it is recommended that the following whitening candidates consult a medical doctor before whitening: (8)

* Pregnant and lactating mothers

* Patients being treated for a serious illness or disorder, such as immune compromised, AIDS, etc.

* Children under the age of 13 years

* Light-sensitive individuals including those on PUVA (Psoralen + UV Radiation) or other photochemotherapy (for light-activated whitening systems) Patients taking any photo-reactive drugs or substances, whether over-the-counter, prescription, or homeopathic

Whitening Treatment Options

According to the ADA, whiteners can be categorized in two major groups: bleaching agents (peroxide containing) and non-bleaching agents. Whitening products can be may be administered by dentists in the dental office, dispensed by dentists for home-use, or purchased over-the-counter (OTC). Even though teeth whitening is considered a cosmetic procedure and is not covered by dental insurance, patients often request it.

The three types of peroxide-containing bleaching treatments available to patients include:

* In-office whitening (professionally applied)

* At-home whitening (professionally dispensed)

* Over-the-counter (OTC) whitening (consumer purchased)

In-office and at-home professional whitening are the safest methods, because they are monitored by dental professionals. The whitening results of in-office and at-home whitening products are also more dramatic than OTC whitening products since they contain higher levels of carbamide or hydrogen peroxide agents. Even though in-office and at-home professional whitening products are more expensive than OTC whitening products, ranging from $300 to $500, many patients prefer the convenience, reliability, and the professional monitoring they receive.

For those patients and consumers who want more affordable whitening options, a variety of OTC whitening products are safe, reliable, and effective. It is important to note that these products will not achieve the same dramatic results that can be achieved with the dentist-supervised products.

In general, most in-office whitening system contain higher hydrogen peroxide concentrations, ranging from 15 to 38 percent, while at-home whitening systems contain lower hydrogen or carbamide peroxides ranging from 3 to 10 percent. (1)

Among the more popular treatment options today are in-office teeth whitening solutions, otherwise known as one-hour whitening. Although it can be expensive, at approximately $500 for an in-office whitening treatment, many patients like the one-hour convenience. Because in-office whitening systems involve using higher concentrations of hydrogen peroxide, this whitening option allows the patient to see noticeable results, in some cases up to five to eight shades lighter in only one hour. As noted earlier, it is important to explain to the patient that results can vary.

In-Office Treatment: In-office whitening systems can use either a chemically activated agent or light-activated agent, depending on the product used. When using a light-activated agent, additional steps are required to protect the lips and surrounding tissues from being burned or irritated from the high intense light that is used. In most cases, depending on state regulations, a trained expanded functions dental assistant can perform this procedure under the direct supervision of the dentist following a consult and patient exam with the dentist. Consider the following recommendations:

* Use a shade guide to note shade of the teeth before whitening.

* Place cheek retractors and patient napkin (for patient comfort).

* Place cotton rolls in the maxillary and mandibular vestibules to protect the buccal mucosa.

* Fold gauze squares into triangles and place each into the posterior buccal mucosa area, tucking ends between the cotton roll and check retractor to further protect the buccal mucosa.

* Isolate the teeth with a light-reflective resin (light-cured) barrier or dental dam to protect the gingiva.

* Apply the whitening agent to the facial surfaces of the teeth for either two 20-minute applications, for a total of 40 minutes of treatment time, or four 15-minute applications for a one-hour total treatment time, depending on the product and method used (see manufacturer's instructions).

* Direct a light or laser source on the teeth to accelerate or activate the light-activated whitening agent and monitor the patient, or monitor the patient for a chemically activated whitener (depending on the product used).

* Remove the whitening agent from the teeth using the HVE with surgical suction tip.

* Remove the dental dam barrier with cotton pliers and cheek retractors.

* Rinse the teeth using water from the air/water syringe and suction with the HVE. Use caution because teeth may be sensitive to cold water.

* Use a shade guide to note the shade of the teeth after whitening.

* Document in the chart the product used, the before-whitening shade, the after-whitening shade, and note any adverse reactions to the treatment, such as tooth sensitivity.

Some popular professional products on the market today are:

* Ultradent Opalescence Boost PF, a chemically activated 40 percent hydrogen peroxide gel that contains potassium nitrate and fluoride. (9)

* Philips Zoom! Whitening, a light activated gel that contains potassium nitrate and fluoride. (10)

When a patient chooses either in-office whitening system, the dentist may provide the patient with whitening trays and whitening gel (syringes) to use for at-home touch ups or to improve whitening results, which can be included in the price.

At-Home Treatment Under Dentist's Care: Another popular treatment option for patients today is using professional whitening agents at home under the care and supervision of the dentist. As previously mentioned, at-home whitening systems contain lower hydrogen or carbamide peroxide than in-office whitening systems. Although this method takes longer than the in-office method, patients choose this method because of its affordability compared to in-office whitening. With these methods, the whitening material will typically stay on the teeth for up to one hour per day, depending on the percentage of the whitening gel, and is used over a two-to-four-week period to achieve professional whitening results. Patients can anticipate up to six tooth shades lighter.

In one option, the patient uses custom-fitted trays along with a whitening gel that costs approximately $350. Along with the custom trays, patients are provided two to three whitening gel syringes. Having the whitening gel in syringe form helps the patient easily load the whitening gel into the custom-fitted trays. The levels of carbamide peroxide available for patients for at-home use are commonly 10 percent, 15 percent, and 20 percent. However, some manufacturers are now making 35 percent and 45 percent available for at-home use. Additionally, the whitening gel is usually available in flavors, such as mint or melon. Patients can expect to see noticeable results within one week, when wearing the trays 30 to 60 minutes per day with 10 percent carbamide peroxide and 15 to 20 minutes per day with 15 percent carbamide peroxide. (11) To start this procedure, the patient will schedule two appointments initially, followed by two short appointments.

During the first appointment, the dentist will meet briefly with the patient to:

* Examine the teeth for preexisting restorations.

* Discuss the common adverse effects such as tooth sensitivity and gingival irritation.

* Discuss the risk of increasing sensitivity following whitening.

* Discuss the potential that existing restoration may not match the whitening shade.

* Determine the appropriate carbamide percent level for whitening.

Also during this appointment, the dental assistant will take maxillary and mandibular alginate impressions and determine the existing shade of the teeth prior to whitening. After the patient leaves the first appointment, the dental assistant will pour up the impressions with gypsum or white plaster to make dental models; apply a light-cured block out material to the facial surfaces of teeth, excluding the molars (usually); cure the resin block-out material using a curing light; and construct vacuum-formed custom trays using a thermoplastic resin material and the vacuum form machine.

During the second appointment, the dental assistant delivers a whitening kit to the patient. The whitening kit will include the custom whitening trays, whitening gel syringes, storage case, and written instructions. During this visit, the dental assistant will discuss the instructions for whitening, which include the frequency and whitening time recommended; demonstrate how to load the whitening gel into the trays; and review the protocol if the patient should have sensitivity.

Next, the patient will schedule two additional appointments, where the patient will come in for shade checks, which will determine if he or she should continue the whitening procedure.

Some popular professional products on the market today are:

* Ultradent Opalescence (R) PF- available in 10, 15, 20, 35, and 45 percent Carbamide Peroxide with Potassium Nitrate and Fluoride (11)

* Philips Zoom DayWhite (Hydrogen Peroxide formulation) available in 6, 9.5, and 14 percent hydrogen peroxide (12)

* Philips Zoom NiteWhite (Carbamide Peroxide formulation) available in 22 and 16 percent hydrogen peroxide (12)

Another professional at-home whitening treatment involves the patient using universal or "one size fits all" disposable trays that are prefilled with 10 percent or 15 percent hydrogen peroxide whitening gel. This convenient method eliminates the need for the patient to schedule appointments for impressions and delivery of whitening trays. It also saves the dentist office time making models and lab time. Patients can expect to see noticeable results wearing these trays within one week, when wearing 30 to 60 minutes per day with 10 percent hydrogen peroxide, and 15 to 20 minutes per day with 15 percent hydrogen peroxide. (13) This whitening option will cost the patient approximately $100 to $125 for a box of 10 prefilled trays, which is equivalent to five whitening treatments (one tray for the maxillary teeth and one for the mandibular teeth).

A popular professional product on the market today is:

Ultradent Opalescence Go[R] Prefilled Whitening Trays - 10 percent and 15 percent Hydrogen Peroxide. (13)

OTC Solutions: Consumers have a number of over-the-counter products to choose from today that are produced by oral health companies, although these products will not produce the dramatic results of professional dentist-prescribed whitening products. The ADA recommends that consumers purchase products that have the ADA Seal of Acceptance to ensure products are safe, reliable, and effective.

There are four types of over-the-counter whitening products, most of which can be purchased at pharmacies and department stores:

* Brush-on whitening is an over-the-counter whitening product applied to the teeth by brushing the whitening gel onto the facial and buccal surfaces. It is important to explain to patients that because brush-on whitening gels contain a low percentage of peroxide, they should expect a minimum amount of whitening and that this whitening option will remove extrinsic or surface stains only. Additionally, inform patients that salvia flow can inhibit the effectiveness of this product and can cause blotches on the teeth if it is not used properly. (4)

* Whitening strips are thin, flexible plastic strips that are coated with a hydrogen peroxide gel and an adhesive. After peeling off the backing of the strips, patients press the strips up to the gingival margins and across the facial and buccal surfaces of the maxillary and mandibular teeth. After the initial placement, the strip excess is overlapped and pressed onto the lingual surfaces. With advances in adhesives, whitening strips have become a popular over-the-counter choice. Consumers can see visible results in seven to 10 days. (4)

* Teeth whitening kits use a homemade fitted tray along with a whitening gel. The results can be long lasting with minimal adverse effects. The universal trays used are made to fit by boiling in water, allowing them to cool slightly, and then placing into the mouth so that they can be pressed and molded to the teeth. After the trays are cooled, the consumer can place the whitening gel into the trays and wear them for approximately 30 minutes per day up to several days.

* Whitening rinses contain oxygen sources such as hydrogen peroxide to effectively react with the chromogens to whiten teeth. (3) When following manufacturer's instructions by rinsing twice a day for 60 seconds, patients can expect to a one to two shade difference in tooth color under normal circumstances.

* Whitening toothpastes contain chemical agents that are designed to improve tooth appearance by removing extrinsic or surface stains. Some whitening toothpastes are dispensed through dental offices, while others are sold over the counter. Because whitening toothpastes typically contain higher amounts of abrasives and detergents than standard toothpastes, to remove tougher stains, they accomplish stain removal through gentle polishing, chemical chelation, or some other non-bleaching actions. It is important to mention, though, that some may contain low concentrations of carbamide peroxide or hydrogen peroxide, which can lighten tooth color by about one or two shades. (3) The ADA recommends that consumers choose an OTC whitening toothpaste that has the ADA Seal of Acceptance to ensure that it is safe and effective.

Helping Patients Choose the Best Option

There are many whitening products on the dental market to choose from today. As dental professionals, it is important to understand the composition of whitening materials, indications for use, precautions, contraindications, the potential adverse effects to whitening, and the options available to patients, so that you can advise patients on the best choice for their care and their budget. The ADA recommends that consumers should only choose a whitening product after a consultation and thorough examination with a dentist. (1) A dentist consultation and examination are important to determine if whitening is an appropriate type of treatment, especially for patients with many fillings, crowns, and extremely dark stains. If patients choose not to have professional teeth whitening performed, it is important to advise them to choose a whitening product that has the ADA Seal of Acceptance and to follow the manufacturer's instructions to avoid any adverse effects.

By Betty Leh, CDA

Betty Leh, CDA, EFDA, EFODA is a dental assisting instructor at Erwin Technical College in Tampa, FL. Leh has worked in private practices as an expanded functions dental assistant sand as a dental product manager for a dental distributor where she discovered her passion for dental education. She is currently attending the University of Central Florida where she will earn her B.S. degree in technical education and industry training later in 2018.

REFERENCES

(1.) American Dental Association. Tooth whitening/bleaching: Treatment considerations for dentists and their patients. American Dental Association. [Online] 2009. [Cited: August 1, 2018.] https://www.ada.org/-/media/ADA/About%20the%20ADA/Files/whitening_bleaching_treatment_considrations_for_patients_and_dentists.pdf?la=en.

(2.) --. Statement on the safety and effectiveness of tooth whitening products. American Dental Association. [Online] 2012. [Cited: August 1, 2018.] https://www.ada.org/en/about-the-ada/adapositions-policies-and-statements/tooth-whitening-safety-and-effectiveness.

(3.) Tooth whitening: What we now know. Carey, Clifton M. 14 Suppl, 2014, The Journal of Evidence-Based Dental Practice, pp. 70-76.

(4.) Bird, Doni L. and Robinson, Debbie S. Modern dental assisting. 12th. St. Louis : Elsevier Saunders, 2018. pp. 743, 831-832.

(5.) Itradent Products, Inc. Benefits of potassium nitrate and fluoride. Ultradent Products, Inc. [Online] 2018. https://www.opalescence.com/za/pages/press-room.aspx?article-name=Benefits%20of%20Potassium%20Nitrate%20and%20Fluoride.

(6.) Tam, L. Effect of potassium nitrate and fluoride on carbamide peroxide bleaching. National Center for Biotechnology Information, U.S. National Library of Medicine. [Online] 2001.

(7.) Haywood, V.B., Caughman, W.F., Frazier, K.B. and Myers, M.L. Tray delivery of potassium nitratefluoride to reduce bleaching sensitivity. National Center for Biotechnology Information, U.S. National Library of Medicine. [Online] 2001. https://www.ncbi.nlm.nih.gov/pubmed/12066670.

(8.) Discus Dental, LLC. Philips Zoom chairside whitening directions for use-dentist instructions. Philips Resource Library. [Online] 2010. [Cited: August 12, 2018.] https://www.philips.com/c-dam/b2c/category-pages/personal-care/POHC/resource-library-docs/19_2843_12209_Zoom_Dr_DFU_Multi.pdf.

(9.) Ultradent Products, Inc. In-office whitening: Opalescence Boost PF 40%. Ultradent Products, Inc. [Online] 2018. [Cited: August 2, 2018.] https://www.ultradent.com/en-us/Dental-Products-Supplies/Tooth-Whitening/In-Office-Whitening/Opalescence-Boost-PF-40-percent/Pages/default.aspx.

(10.) Philips, USA. Teeth whitening: In-office whitening treatment. Philips, USA. [Online] 2018. [Cited: August 2, 2018.] https://www.usa.philips.com/c-p/DIS998_11/zoom-ultimate-protocol-in-office-whitening-treatment/overview.

(11.) Ultradent Products, Inc. Take-home whitening: Opalescence PF. Ultradent Products, Inc. [Online] 2018. [Cited: August 6, 2018.]

(12.) Philips, USA. Philips Zoom take-home whitening. Philips, USA. [Online] 2018. https://www.usa.philips.com/c-m-pe/dental-professionals/products/whitening/take-home-whitening.

(13.) Ultradent Products, Inc. Prefilled whitening trays: Opalescence Go. Ultradent Products, Inc. [Online] 2018. https://www.ultradent.com/en-us/Dental-Products-Supplies/Tooth-Whitening/Pre-loaded-Whitening-Trays-Bleaching-to-go/Opalescence-Go-10-and-15-percent-hydrogen-peroxide/Pages/default.aspx?s_cid=2444.

(14.) Undesirable and adverse effects of tooth-whitening products: a review. Goldberg M, Grootveld M, Lynch E. 1, February 2010, Clinical Oral Investigations, Vol. 14, pp. 1-10.
Category         Method                 Option

  Bleaching      In-office whitening    1-hour whitening: Chemically
  Agents         (professionally        activated
  (peroxide      applied)               1-hour whitening: Light
  containing)                           activated
                 At-home whitening      Custom trays w/ whitening gel in
                 (professionally        syringes
                 dispensed)             Universal trays pre-loaded
                                        w/ whitening gel
                 Over-the-counter       Brush on whitening
                 (OTC) whitening        Whitening strips
                 (consumer purchased)   Trays with bleaching gels
                                        Whitening rinses
  Non-Bleaching  Whitening dentifrices  Whitening toothpastes
  Agents
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Author:Leh, Betty
Publication:The Dental Assistant
Date:Sep 1, 2018
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