Tray tooth bleaching 2...Everybody’s teeth respond differently, both in how white they get and how quickly that whitening occurs. Tray bleaching expectations include: t Normally

DentalPracticeSuccess SPRING 2016

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By Van B. Haywood, DMD

If you rob a bank and give the money to the poor, have you done the right thing? If you

restore teeth with the best possible porcelain veneers when the teeth do not need veneers, have you done the right thing?

Bleaching teeth is one of the many treatments that everyone should have in their treatment op-tions in order to do the right thing at the right time. Once you have determined to do the right thing, then you need to do the thing right

(according to the wisdom of my late esteemed colleague Dr. Dick Tucker).

When considering bleaching, the most cost-efficient, safe and effica-cious technique for both the dental office and the patient is generally recognized as tray bleaching using a 10 percent carbamide peroxide (CP).

The following checklist on tray bleaching may be helpful.

1Everybody’s teeth respond differently, both in how white they get and how quickly that

whitening occurs. Tray bleaching expectations include:

t Normally discolored teeth can take three days to six weeks.

t Nicotine-stained teeth can take one to three months.

t Tetracycline-stained teeth can take two to 12 months or longer. The average for tetracycline-stained teeth is three to four months to get lighter, but not necessarily white.

Once teeth reach their maximum whiteness, further treatment or dif-ferent products or concentrations will not improve that shade. Teeth look the

best when they match the color of the sclera of the eyes.

2 Prior to bleaching, the dentist should conduct a proper examination and analysis of

the smile. This examination should include:

t Evaluating how much of the teeth are showing in a full smile because the gingival area of teeth do not bleach as well as the incisal portion.

t Identifying the gummy smile be-cause whiter teeth make the gummy smile more noticeable. Periodontal therapy for altered passive eruption may be first indicated.

t Identifying the existing restora-tions revealed in a full smile because the restorations do not change color.

t Evaluating the results of the periodontal conditions because exposed roots do not bleach.

t Recording all existing decay, gingival disharmony, history of sen-sitivity or occlusal problems.

3 The dentist should take a screening radiograph of the an-terior teeth to be bleached and

any single dark tooth to determine the cause of the discoloration. That cause could include:

t An abscessed tooth.

Tray tooth bleachingThe right thing at the right time

t Internal or external resorption.t Calcific metamorphosis (the

pulp chamber obliterated by second-ary dentin).

t Different size pulp chambers.t Caries.t Cysts or tumors.

4 There are two different bleach-ing materials that require different instructions for the

patients. CP is composed of hydro-gen peroxide and urea. CP is best worn overnight, as it is active for 6 to 10 hours. Hydrogen peroxide (HP) is only active for 30 to 60 minutes, so it is applied during the day. A 10 per-cent CP product is comparable to a 3.5 percent HP product. Because CP has a long activity time, it takes fewer nights to reach the same shade as HP worn during the day. Conversely, HP worn during the day will take more days of less wear time to equal the nighttime bleaching with CP.

5 The pH to get tooth decay on dentin is below 6.8 and in enamel is below 5.5. Because

CP has urea, the pH of the mouth and in the tray is elevated above 8 within five minutes of insertion such that patients cannot get tooth decay while wearing the bleaching tray with CP. Hence CP in a tray may be used for caries control when fluoride in a tray is not working. HP has a pH of 5, so does not favor tooth protection for long-term wear.

6 Different tray designs are im-portant for different products, different concentrations and

different patients. Ten percent CP was originally designed to treat the gingivae as an oral antiseptic (Glyox-

ide), so trays can be made that extend onto the tissue 1-2 mil-limeters for a more comfortable, better seal. The gingival health in research projects always improves during bleaching. Concentra-tions higher than 10 percent require scalloping the tray such that there is no tissue contact to avoid tissue burning.

7 Spacers or reservoirs are not needed to bleach teeth as only a thin film of mate-

rial is required with tray isola-tion, but reservoirs account for tight or ill-fitting trays. A proper alginate impression (where the adhesive has set for 10 minutes in the tray before use, the impres-sion is held in the mouth for one minute past tacky and poured within 15-45 minutes without bubbles) creates an excellent fitting non-scalloped, no reservoir tray for 10 percent CP.

8 Tooth sensitivity is a result of the easy passage of peroxide through intact enamel and

dentin to the pulp in five to 15 minutes. This easy passage changes the color of the dentin as well as the enamel. Sensitivity is a transient pulpitis, and the higher the concen-tration, the greater the sensitivity.

9 In addition to a proper fitting tray and low concentration of CP, the best treatment for

sensitivity involves the tray applica-tion of 5 percent potassium nitrate for 10 to 30 minutes prior or after bleaching. Potassium nitrate is found in most desensitizing toothpastes in the U.S. Professional products are also available, as well as bleaching products, which contain potassium nitrate.

10 Bleaching should notbe started immediately after a prophylaxis. Before

initiating bleaching and to reduce sensitivity issues, it is best to wait two weeks, during which time the

patient should brush with a desen-sitizing toothpaste to further reduce the chance of sensitivity.

11Because bleaching materi-als penetrate the tooth and release oxygen, the bond

strengths of composite to enamel are reduced by 50 percent if bonding is performed immediately after bleach-ing. The dentist should wait two weeks after bleaching for the oxygen to dissipate before initiating bonding procedures.

12 The oxygen released duringbleaching also affects the shade of the tooth, so the

patient should not be bleaching for two weeks prior to a shade being taken for a crown or composite. Since some patients may be using over-the-counter products unknown to the dental office, it is important that the receptionist question the patient before scheduling an appoint-ment that involves bonding or shade matching.

13 Restorations will not changecolor from any type of bleaching. While the surface

will be cleaned, which may result in a more favorable-appearing restoration,


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the color is the same. Patients need to be informed of the cost of replacing unaesthetic restorations as a separate fee from the bleaching fee.

14 A single dark tooth is besttreated with a single tooth bleaching tray rather than a

full-mouth tray. This allows the single tooth to reach its maximum whitening before changes are attempted on the adjacent teeth. A single-tooth tray is fabricated by taking a full mouth tray extended further onto the tissue, and removing the tooth molds so that the bleaching material only contacts the single dark tooth.

While there is much more infor-mation about how to do the

thing right with bleaching, these points provide a starting point for good quality patient care.

professor in the Depart--

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80 inside dentistry | February 2018 | www.insidedentistry.net

Perspective

Throughout history, dentists have provided many ser-vices that change the color of their patients’ teeth. the oldest bleaching techniques date back to the 1800s and were performed in the dental office. today, the most popular bleaching technique involves the use of trays made in the dental office for at-home wear. When the first article on this tray technique was written in

1989, the technique was called “nightguard Vital Bleaching.” As this technique gained popularity in the profession and around the country, dentists became concerned that when discussing “bleaching,” a tech-nique that relied on the patient applying a material in the tray at home, the use of the term “bleach” might lead some patients to use laundry bleach (ie, sodium hypochlorite) in an attempt to change the color of their teeth. therefore, to reduce the potential for patients to become confused and possibly cause harm to themselves, the profession shifted its terminology to the word “whitening,” which sounded both more pro-fessional and less dangerous. in ad-dition, because color measurement instruments are used to measure whiteness values, the term “whiten-ing” has a more scientific basis.

As the esthetic aspect of the den-tal profession has evolved, there has been a proliferation of over-the-counter (OtC) products and tech-niques that claim to perform “whit-ening.” However, in this evolution to a broader group of products and techniques, the definitions of the terms relating to tooth color change have diverged into two meanings: the term “whitening” now primar-ily refers to “the removal of extrin-sic stains from the tooth,” whereas

“bleaching” refers to “changing the in-herent color of the tooth.” Bleaching produces a whitening effect, but in a different manner than products that merely remove surface stains.

Unfortunately, this differentiation between the meaning of “bleaching” and “whitening” has caused some patients to confuse the OtC products sold for “whitening” teeth with the

“bleaching” treatments that a dentist pro-vides. When the American dental Association

Patient education helps eliminate confusion regarding treatment options

Tooth Whitening Is Not Always Tooth Bleaching

approved the first “whitening toothpaste” in 1999, the company had to state on the package what the toothpaste was capable of doing. the label on this whitening toothpaste stated that it “polishes away stains,” but also noted that it “is not bleaching.” today, many toothpastes are being sold as “whitening” toothpastes. A close look at the product bro-chure of one of the popular whitening toothpastes reveals that the toothpaste “does not change the color of the teeth, but removes surface stains.” However, this does not appear until the second page. Because manufacturers have deemphasized this fact, some consumers may believe that whitening toothpaste is an equally effective alternative to bleaching treatments. there has been little research conducted on the many OtC whitening toothpaste products without peroxides, but what has been done has demonstrated that there is no inherent color change in the teeth, only the removal of surface stains.

the challenge with using the scientific term “whitening,” which is the measurement used by colorimeters and other scientific color

measuring instruments, is that the term does not represent what is occurring during “bleaching” treatment. Whether you remove black surface stains from a tooth, paint a tooth white on the surface, or change the internal color of a tooth by bleaching the dentin, the instrument still records that the tooth is “whiter.” However, two of these processes only result in surface color changes, whereas the other achieves a true internal tooth color change.

dentists need to educate their pa-tients that in general marketing terms,

“whitening” products only remove sur-face stains, but “bleaching” treatment changes the internal color of the tooth. Because there is some crossover with a few effective OtC products, this will not totally remove the confusion, but in most circumstances, patients will better understand what type of treatment they

are seeking and use their finances appropriately.

About the AuthorVan B. Haywood, dMd, is a professor in the department of restorative sciences at the dental College of Georgia at Augusta University in Augusta, Georgia.

bleaching produces a whitening effect, but in a different manner than

products that merely remove surface stains.

Van B. Haywood, dMd

Originally published in: Haywood V. Tooth whitening is not always tooth bleaching. Inside Dentistry. 2018;14(2):80. Copyright © 2018 to AEGIS Publications, LLC. All rights reserved. Used with permission of the publisher.

38 inside dentistry | January 2018 | www.insidedentistry.net

weeks with an average time of about 2 weeks.2 Comparatively, tetracycline-stained teeth can take 2 to 12 months or longer to bleach using the same method.3 Although they do not nec-essarily become “white,” the average time for tetracycline-stained teeth to lighten is 3 to 4 months (Figure 1 and Figure 2). the final out-come of bleaching tetracycline-stained teeth depends on their initial color and the consis-tency of the color. tetracycline is available in several analogues, which induce different colors in the teeth. Gray discolorations are the hardest to bleach, whereas brown and yel-low discolorations respond better. All teeth will lighten with bleaching; it is the extent to which they will lighten and the uniformity that is unpredictable (Figure 3 and Figure 4).

When bleaching treatment is initiated for normal teeth, there may be minimal color change for a day or two, then the teeth begin to significantly lighten. the teeth will con-tinue to lighten until they reach an endpoint or plateau, which is determined by their com-position, not the product or technique. this contributes to the unpredictable nature of bleaching. Once the teeth reach their maxi-mum whiteness, any further treatment or use of different products/concentrations will fail to improve that shade. teeth look the best when they match the color of the sclera of the eyes, which is the desired endpoint for bleaching.4 However, because the final shade is unpredictable, promising achievement of a super-light shade can result in patient dis-satisfaction with the treatment.

When bleaching treatment is initiated for tetracycline-stained teeth, a slight color change may occur during the first few days, followed by no observable change for a month or so of treatment. After approximately 1 to 2 months, the teeth will begin to lighten in the same manner as normal teeth, progressing until they reach their maximum whiteness potential (Figure 5 and Figure 6). Although the average treatment requires 3 to 4 months of nightly bleaching with 10% carbamide peroxide, reaching the maximum whiteness could take as long as 15 months, depending on the initial color and location of the tetra-cycline staining. to ensure that the lightest shade possible is achieved, before terminat-ing treatment, the patient should continue bleaching for an entire month despite no discernible color change.

The Importance of the Bleaching ExaminationPrior to using any bleaching technique, a proper examination and analysis of the smile should be conducted.5 in addition to the smile itself, this evaluation should include the entire face and account for the sclera of the eyes. the examination should evaluate the extent of the teeth visible in the full smile because the gin-gival areas of teeth do not bleach as well as the incisal portion (Figure 7 and Figure 8). this difference in tooth response exists because the tooth is thicker at the gingiva—with less enam-el and more dentin—and the composition of the dentin varies from the incisal to the root tip. With tetracycline-stained teeth, the gingi-val area is even more difficult to bleach. this is because the tooth color comes primarily from the dentin where the tetracycline molecule is more tightly bound (Figure 9 and Figure 10).

When planning to bleach normal teeth, identification of a “gummy smile” is impor-tant because whiter teeth will make it more noticeable. Periodontal therapy for altered

I n order to understand how to successfully bleach tetracycline-stained teeth, one must first un-derstand the basics of bleaching normal teeth. When considering bleaching, most dentists choose the most cost-effec tive, safest, and

efficacious technique for both the dental of-fice and the patient, which is generally recog-nized to be overnight tray bleaching using a 10% carbamide peroxide bleaching agent—the most researched AdA approved bleaching ma-terial.1 in bleaching cases involving tetracy-cline-stained teeth, the extended time required for the teeth to change color makes choosing the appropriate bleaching material and tech-nique even more important in terms of both cost and safety. When addressing patients, the word “bleaching” should be used instead of

“whitening.” Although many over-the-counter products claim that they can produce “whiten-ing” that rivals dentist treatments, “whitening” removes surface stains only, whereas “bleach-ing” changes the inherent color of the teeth. the following article compares and contrasts tray-bleaching techniques for normal teeth with those for tetracycline-stained teeth.

How Teeth Respond to Bleachingevery patient’s teeth respond differently to bleaching, both in the level of bleaching that they obtain and how quickly that bleaching occurs. depending on the final shade desired, overnight tray bleaching of normal discol-ored teeth takes approximately 3 days to 6

Bleaching Tetracycline-Stained TeethConsiderations and recommendations for treatmentVan B. Haywood, DMD | Rhoda J. Sword, DMD

InsidereSToraTive

peeR-ReVieweD

Van B. Haywood, dMdProfessordental College of Georgiaaugusta UniversityAugusta, Georgia

RHoda J. SwoRd, dMdassociate Professordental College of Georgiaaugusta UniversityAugusta, Georgia

Originally published in: Haywood V. Sword R. Bleaching Tetracycline-Stained Teeth. Inside Dentistry. 2018;14(1). Copyright © 2018 to AEGIS Publications, LLC. All rights reserved. Used with permission of the publisher.


(1.) Preoperative tetracycline-stained teeth to be bleached nightly with 10% carbamide perox-ide in a non-scalloped, no-reservoir tray. (2.) Overnight bleaching of one arch for 3 months to 4 months with 10% carbamide peroxide shows improvement, but not as significant as normal teeth would demonstrate. (3.) Preoperative tetracycline staining in a bruxism patient often requires several trays for extended treatment. (4.) Posttreatment with 10% carbamide peroxide, teeth are lighter, but not white. One arch treatment improves compliance and helps demon-strate effectiveness. (5.) Moderately tetracycline-stained teeth that demonstrate uniform discol-oration without severe gingival discoloration. (6.) Several months of overnight treatment with 10% carbamide peroxide yields a reasonable outcome, which greatly pleased the patient.

fig. 6fig. 5

fig. 4fig. 3

fig. 2fig. 1

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passive eruption may be indicated prior to bleaching to expose more of the teeth and eliminate the excessive gingival display, which can reduce the need for bleaching. in order to appear normal, most teeth should be at least 10 mm in length. the presence of a gummy smile may be less of a problem when planning to bleach tetracycline-stained teeth. Because their gingival areas are often darker and do not respond as well, tetracycline-stained teeth will not create the same sharp contrast with the gingiva that is observed in a gummy smile with lighter teeth.

existing restorations revealed in a full smile should be evaluated for visibility and criticality of color because they will not lighten with bleaching, regardless of the ma-terial. some surface stain removal may oc-cur on composites, but the basic color of the

restorations will remain the same. therefore, if a restoration matches the existing color of the tooth, it may become unesthetic after bleaching and need to be replaced. Patients must clearly understand the financial im-plications of replacing unesthetic, tooth-colored restorations for an additional fee, because that cost may present an obstacle to proceeding with bleaching.

Periodontal conditions and gingival re-cession should be evaluated during smile analysis because exposed roots do not bleach. tetracycline-stained teeth are even darker at the gingival than normal teeth, so the expec-tations of these patients should be adjusted to a less-than-ideal outcome. in addition, the smile analysis for both types of teeth should include an evaluation for gingival disharmo-ny because lightening teeth with bleaching

will accentuate any less-than-ideal areas (Figure 11 and Figure 12).

As with normal teeth, tetracycline-stained teeth should be examined for existing decay. Because the decay process is halted during bleaching with 10% carbamide peroxide, small non-sensitive caries do not have to be restored prior to treatment.6 However, if a deep or sensitive lesion is detected, a protective res-toration using a resin-modified glass iono-mer (rMGi) can be placed prior to initiating bleaching. Because predicting the final bleach-ing color outcome is impossible, the shade se-lection for the rMGi must be estimated. After bleaching is complete, if the rMGi no longer matches or has the desired surface gloss, its surface can be removed, leaving the deeper portion as a base. then a composite resin that matches the shade of the bleached teeth can be bonded to the rMGi and surrounding enamel to achieve better esthetics.

Sensitivity during BleachingAll patients who are considering bleaching treatment should be evaluated for a history of sensitivity. those with existing sensitivity issues are more likely to experience increased sensitivity during bleaching. sensitivity dur-ing bleaching treatment results from the easy passage of the peroxide through the intact enamel and dentin and into the pulp, which occurs in 5 to 15 minutes.7 Bleaching sensitiv-ity is a transient pulpitis resulting from this easy passage, and higher concentrations of bleaching materials will result in greater sen-sitivity.8 in addition, sensitivity can be caused by occlusal problems related to the tray.

Beyond using a low concentration of carb-amide peroxide and a proper-fitting tray, the addition of a 10 to 30 minute tray application of 5% potassium nitrate prior to or after bleaching treatment can help reduce associated sensitiv-ity.9 Potassium nitrate is found in most desen-sitizing toothpastes in the United states, but is less used in other countries. With various professional products available for dispensing potassium nitrate, it can be applied by brushing with a toothpaste, using it in the tray instead of the bleaching material, or incorporating it into the bleaching material. When applied using the tray, a 5% potassium nitrate toothpaste worn for 10 to 30 minutes will successfully reduce sensitivity in more than 90% of bleaching pa-tients. For patients with a history of sensitivity, brushing with a desensitizing toothpaste con-taining 5% potassium nitrate for 2 weeks prior

www.insidedentistry.net | January 2018 | inside dentistry 41

(7.) Tetracycline discoloration is not located at the difficult gingival area in this patient, which im-proves the prognosis. (8.) Four months of nightly bleaching yields an excellent result due to the type and location of the tetracycline staining. (9.) Tetracycline discoloration at the gingival area is less predictable, especially with multiple analogs causing different discolorations. (10.) Bleach-ing yields improvement, but not much change at the gingival area, even with use of a non-scalloped tray. (11.) Moderately tetracycline-stained teeth with exposed root surfaces require informing the patient of the prognosis of the exposed root. (12.) Six months of nightly bleaching with 10% carbamide peroxide lightens the teeth, but the root surfaces remain discolored.

fig. 11

fig. 9

fig. 12

fig. 10

fig. 8fig. 7

A pH level below 6.8 is necessary for tooth decay to occur in dentin, and a pH level be-low 5.5 is necessary for it to occur in enamel. Because carbamide peroxide has urea, it el-evates the pH level of the mouth above 8.0, significantly reducing patients’ ability to de-velop tooth decay during bleaching treatments. Hydrogen peroxide has a pH of 5, so it does not favor tooth protection. Because of the long-term tray wear necessary in the treatment of tetracycline-stained teeth, the use of 10% carb-amide peroxide overnight is recommended.

Tray Fabricationthe bleaching tray design selected should be informed by the product to be used, its concentration, and the specific needs of the patient. Products containing 10% carbamide peroxide were originally designed to treat the gingivae as an oral antiseptic (eg, Gly-Oxide®).

therefore, when planning to use a 10% carb-amide peroxide bleaching material, trays can be made that extend 1 to 2 mm onto the gin-gival tissue for a more comfortable fit and a better seal to retain the material. the gingival health of patients involved in bleaching re-search projects using this concentration and tray type has been shown to improve during bleaching. the use of carbamide peroxide concentrations higher than 10% requires scal-loping the tray so that the material does not come in contact with the gingival tissue and potentially cause a burn. For long-term wear to treat tetracycline-stained teeth, the non-scalloped tray with 10% carbamide peroxide provides the most efficient bleaching possible with the least gingival or tooth sensitivity.

in tray fabrication, spacers or reservoirs are not needed to bleach teeth; they are de-signed to account for tight or ill-fitting trays.

to beginning bleaching treatment can signifi-cantly reduce bleaching sensitivity.10

sensitivity generally occurs during the first 2 weeks of bleaching treatment. Although the tetracycline-stained patient will require bleaching treatment that lasts for many months, the sensitivity does not usually be-come progressively worse. to further reduce sensitivity issues, practitioners should wait 2 weeks after a prophylaxis before initiating bleaching, during which time the patient can brush with a desensitizing toothpaste.

Screening RadiographsBefore the initiation of bleaching treatment, a screening radiograph should be taken of the anterior teeth and any individual dark teeth to determine the cause of their discoloration. Oftentimes, an abscessed tooth or internal or external resorption fails to exhibit any as-sociated signs or symptoms other than tooth discoloration. in tetracycline-stained teeth, these color variances are more difficult to rec-ognize. Additionally, calcific metamorphosis, in which the pulp chamber is fully or partially obliterated by the deposition of secondary dentin, can cause a tooth to appear darker. the screening radiograph can also be use-ful in determining the presence of any inter-proximal caries or periapical cysts or tumors that could be contributing to the darkened appearance of a tooth or teeth.

Bleaching Materialsdifferent patient instructions are required for each of the two most used bleaching ma-terials: carbamide peroxide and hydrogen peroxide. Carbamide peroxide is composed of hydrogen peroxide and urea. Because it is active for 6 to 10 hours, carbamide perox-ide is best used in overnight tray bleaching.11 Hydrogen peroxide is only active for 30 to 60 minutes, so it is more appropriate for use during the day. A 10% carbamide peroxide product is comparable to a 3.5% hydrogen peroxide product. Because carbamide per-oxide has a longer activity time, it requires less treatments to reach the same shade when compared with the use of hydrogen peroxide during the day. For normal teeth, patient preference and lifestyle can deter-mine the most appropriate material and wear time. However, for tetracycline-stained teeth, overnight tray bleaching with 10% carbamide peroxide is the most time-efficient and re-sults in a high rate of patient compliance.


A proper alginate impression (ie, the material is allowed to set properly in the tray before use, held in the patient’s mouth for the ap-propriate manufacturer recommended time, and used to pour the model within 15 minutes to 45 minutes without bubbles) can be used to create an excellent fitting, non-scalloped, no-reservoir tray for 10% carbamide perox-ide bleaching. not using reservoirs both con-serves the amount of bleaching material used and increases the comfort to the patient, es-pecially during the extended bleaching times required to treat tetracycline-stained teeth.

Composite BondingBecause bleaching materials penetrate the teeth and release oxygen, when bonding is performed immediately after bleaching, the bond strength between the composite and the enamel is reduced by approximately 50%.12 therefore, dentists should avoid initiating bonding procedures until 2 weeks after bleach-ing treatment to give the oxygen time to dis-sipate. the oxygen released during bleaching also affects the shade of the teeth, so patients should not bleach for 2 weeks prior to a shade being taken for a crown or composite. Because some patients may be using over-the-counter

products unknown to the dental office, it is important that the receptionist also question them about any of these products that they may be using before scheduling an appoint-ment that involves bonding or shade matching.

Fees for Extended Bleaching Treatmentsthe non-specific and longer treatment times required to bleach tetracycline-stained teeth create a unique challenge for the practitioner concerning fees. if quoted a price for the full treatment time, the potential bleaching pa-tient could be discouraged from proceeding with the treatment. One successful model in-volves charging a reasonable initial bleaching fee for the maxillary arch, while educating the patient that any subsequent treatment and material refill costs will depend on the length of the bleaching process. nationally, one arch of at-home bleaching averages around $285, which includes the examination, the radio-graph, the tray, and the bleaching material. A typical bleaching kit will treat one arch for roughly 4 weeks, and a form can be used by patients to keep track of how quickly they are using the syringes as well as to record any color changes or sensitivity. At the 1-month,

follow-up appointment, this form can be used by the dentist to help determine a fair cost for the patient, including the amount of material needed for another month of treatment and an additional office visit. to further reduce the cost, the dentist should use a company that offers refills to sell to patients instead of full kits. Because they can potentially save money, patients tend to become very efficient with the bleaching material. this “pay as you go” approach benefits both the patient and the dentist. the patient can anticipate the monthly cost, and the dentist does not lose money from unanticipated extended treat-ment times. At each appointment, the dentist and patient can determine if another month of treatment is needed or if it is time to begin bleaching the mandibular arch.

Single arch Treatmentthe dental practice needs to offer a single arch fee. the best way to maximize patient compliance and compare progress from the baseline shade is to treat only one arch at a time. in addition, patients can become discour-aged from initiating treatment by a higher fee that includes both arches and may have other reasons for wanting to bleach the maxillary arch only. in bleaching research projects per-formed free of charge to the participants, sur-prisingly, some patients choose not to bleach the mandibular arch—even at no cost. the option of wearing only one tray has several other advantages. Because there is only one thickness of material between the teeth, this approach minimizes the impact of tray bleach-ing on occlusion, which can reduce mechanical tooth sensitivity and eliminate potential joint problems. And because fewer teeth are being treated simultaneously, overall tooth sensitivi-ty can be reduced as well. single arch bleaching treatment is especially indicated in long-term treatment situations, such as for tetracycline staining, because patients can otherwise lose their reference for how dark their teeth were prior to treatment and become dissatisfied that limited progress is being made. Using a single arch approach provides many advantages, in-cluding reduced impact on occlusion, reduced overall sensitivity, and most importantly, in-creased patient compliance and satisfaction.

Patient ComplianceMaintaining patient compliance for 2 to 6 months of at-home bleaching treatment for tetracycline-stained teeth may seem daunting

(13.) Porcelain ve-neers were placed over tetracycline-stained teeth prior to attempting bleaching, which often requires more opaque veneers. (14.) Nightly bleach-ing with 10% carb-amide peroxide for 4 months lightens the teeth, which can change the ap-parent shade of the veneers if they are not too opaque.

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to the dentist. However, with careful treatment presentation and pa-tient understanding of the benefits, it can be achieved. Much like ad-justing to a bruxism splint or an anti-snoring device, with nightly wear, patients can become accustomed to the use of a whitening tray. the use of 10% carbamide peroxide for long-term wear is ideal for a number of reasons. Compliance is better with overnight tray use, and the patient gets the greatest benefit per application due to its longer activity time, which reduces cost. For example, when using carbamide peroxide, approximately 50% of the peroxide is depleted within 1 to 2 hours. However, the remaining material will continue to release peroxide for another 2 to 6 hours. therefore, if the patient only bleached for 2 hours before removing the tray, he or she would be discarding half of the active material, greatly reducing the efficiency of the individual treat-ment and unnecessarily increasing the cost of the bleaching process.

Bleaching vs Veneersseveral factors should be considered when choosing whether or not to bleach tetracycline-stained teeth. Because the teeth lighten from the incisal to the gingival, the location of the darkened areas will have an impact on the final result. teeth with the darkest discoloration at the cementoenamel junction, especially dark, blue-gray areas, have the poorest prognosis for full lightening, whereas teeth with discoloration in the incisal third have the best prognosis. teeth that are not able to be fully bleached at the gingival third may be good candidates for porcelain veneers. Bleaching prior to veneer preparation can help de-termine if veneers are necessary, and when they are, it can better their

esthetics by providing lighter teeth as a starting point. Alternatively, teeth can be bleached from the lingual after veneer placement (Figure 13 and Figure 14).13 in cases involving tetracycline-stained teeth, when bleaching treatment is attempted prior to recommending veneers, patients can be confident that the most conservative treatment plan was used to achieve the most esthetic result.

ConclusionAlthough the tooth discoloring effects associated with tetracycline in-gestion in children have been recognized in the medical field for some time, tooth staining associated with adult ingestion of tetracycline analogs (eg, minocycline for acne treatment) also has been reported.14 Because of the drug’s continued use to treat acne and other infec-tions, such as rocky Mountain spotted fever, tetracycline staining will continue to occur. due to its financially and clinically conservative approach, bleaching should be the initial treatment for patients with tetracycline-stained teeth.15 Whether the case involves tetracycline-stained teeth or normal teeth, the most effective, cost-efficient, and safest bleaching technique is at-home, overnight bleaching with 10% carbamide peroxide in a non-scalloped, no-reservoir tray.

References1. Christensen GJ. Bleaching teeth—which way is best? J Esthet Restor Dent. 2003;15(3):137-139.2. Haywood VB. the “bottom line” on bleaching 2008. Inside Dent. 2008;4(2):82-89.3. Haywood VB, Leonard rH, dickinson GL. efficacy of six months of nightguard vital bleaching of tetracycline-stained teeth. J Esthet Dent. 1997;9(1):13-19.4. Mrazek B. “don’t bleach until you see the white of their eyes.” Compend Contin Educ Dent. 2004;25(6):472-476.5. Haywood VB. Pre-bleaching examination vital for optimum whitening. Compend Contin Educ Dent. 2012;33(1):72-73.6. Bentley Cd, Leonard rH, Crawford JJ. effect of whitening agents containing carbamide peroxide on cariogenic bacteria. J Esthet Dent. 2000;12(1):33-37.7. Cooper Js, Bokmeyer tJ, Bowles WH. Penetration of the pulp chamber bycarbamide peroxide bleaching agents. J Endod. 1992;18(7):315-317.8. Matis BA, Wang y, Jiang t, eckert GJ. extended at-home bleaching of tetracycline-stained teeth with concentrations of carbamide peroxide. Quintessence Int. 2002; 33(9):645-655.9. Haywood VB, Caughman WF, Frazier KB, Myers ML. tray delivery of potas-sium nitrate–fluoride to reduce bleaching sensitivity. Quintessence Int. 2001;32 (2):105-109.10. Browning Wd. Haywood VB. Hughes n, Cordero r. Prebrushing with a potas-sium nitrate dentifrice to reduce tooth sensitivity during bleaching evaluated in a practice-based setting. Compend Contin Educ Dent. 2010;31(3):220-225.11. Matis BA, Cochran MA, eckert G. review of the effectiveness of various tooth whitening systems. Oper Dent. 2009;34(2):230-235.12. da silva Machado J, Candido Ms, sundfeld rH, de Alexandre rs, CardosoJd, sundefeld ML. the influence of time interval between bleaching and enamel bonding. J Esthet Restor Dent. 2007;19(2):111-118.13. Haywood VB, Parker MH. nightguard vital bleaching beneath existing porcelain veneers: a case report. Quintessence Int. 1999;30(11):743-747.14. Cheek CC, Heymann HO. dental and oral discolorations associated with mino-cycline and other tetracycline analogs. J Esthet Dent. 1999;11(1):43-48.15. Leonard rH, Haywood VB, Caplan dJ, tart nd. nightguard vital bleaching of tetracycline-stained teeth 90 months post-treatment. J Esthet Restor Dent. 2003; 15(3):142-153.

34 inside dentistry | June 2019 | www.insidedentistry.net

50% of patients who bleached their top arch chose not to bleach their bottom arch, even when it was offered at no cost and they were without previous bleaching problems. some patients have stated that because no one sees their bottom teeth, they simply have no fur-ther interest in pursuing bleaching treatment. therefore, approximately 50% of patients who are interested and willing to pay for top-arch bleaching find bleaching their bottom arch to be an unnecessary investment in time and money. in addition, bleaching one arch at a time can improve patient compliance because the color contrast between arches is visually evident (Figure 1). Moreover, one-arch bleaching helps with the reduction of generalized sensitivity because there are less teeth involved, and it helps to avoid occlusal issues because only a single tray is worn dur-ing the treatment. Lastly, a “one-arch” fee is all that is required if one arch is a denture that opposes a patient’s natural teeth. therefore, dental offices should offer a one-arch fee to patients as a viable treatment plan option.

Single Dark Tooth BleachingA single dark tooth that is contraindicated for root canal therapy can be bleached exter-nally using a “single-tooth” bleaching tray.5,6 Because peroxide passes through intact enam-el and dentin and gets to the pulp in 5 to 15 minutes, it is unnecessary to open the pulp

chamber or perform an endodontic therapy to obtain internal access. A vital single tooth can be bleached just as easily from the “outside in” as from the “inside out.” the bleaching code for a single dark tooth tray is the same as a “per-arch” full tray (ie, d9975). the dif-ference is in the tray fabrication, which only allows the bleaching material to contact the single dark tooth without changing the shade of the adjacent teeth (Figure 2). this allows the opportunity for the single dark tooth to either match the color of the adjacent teeth or become lighter than the adjacent unbleached teeth. in the latter case, an additional full tray is fabricated on the same cast, and the adjacent teeth are bleached to match the new shade.

depending on the approach to treatment, a single, dark endodontically-treated tooth presents several options for the fees and codes. A single dark tooth that has received endodontic therapy can be bleached from the inside using the “walking bleach” technique.7 in this technique, the inside of the pulp cham-ber is cleaned of pulp debris, the gutta-percha is removed to 2 mm below the cementoenam-el junction, and a barrier (ie glass ionomer) is placed over the gutta-percha. next, a bleach-ing medicament (ie hydrogen peroxide, sodi-um perborate, carbamide peroxide) is placed into the pulp chamber and the endodontic access is temporarily sealed. the “internal” bleaching material must be changed weekly, from one to six times, depending on the de-sired tooth color. the AdA code for “internal bleaching per tooth” is d9974. However, this process can lead to multiple dental visits and become time-consuming for both the patient and the provider. Because the process of in-ternal bleaching can take from one to six vis-its, the amount of “meet, greet, and seat” time for the patient, as well as the treatment and

Determining appropriate fees for tooth bleaching in a dental office should take into account several considerations, which are based upon the diagnosis of the cause of discolor-

ation and the patient’s concerns. the national average cost of tray bleaching is between $260 and $320 per arch, which includes the exami-nation, screening radiographs, impressions, trays, and other needed materials.1 tooth

“bleaching” materials are generally different from tooth “whitening” products that are marketed as toothpaste and other over-the-counter dentifrices. “Whitening” products generally only remove the stains from the ex-ternal surfaces of the teeth, whereas “bleach-ing” products penetrate deep within the tooth structure, changing the internal color of the tooth, which resides in the dentin.2,3 When offering tray bleaching to patients, consider the following tips to help determine the most appropriate treatment and the most cost-ef-fective way to code for the treatment rendered.

One Arch at a Timethe American dental Association’s (AdA) code for external bleaching for home ap-plication is d9975, which is a “per-arch” treatment.4 surprisingly, the results of early bleaching research indicated that almost

Determining Appropriate Fees for Tooth BleachingTips for approaching treatment and coding it in a cost-efficient mannerVan B. Haywood, DMD | Jacqueline Delash, DMD, MPH

peer-reviewedrestorative

inside

VAn B. HAywOOD, DMDProfessorDepartment of Restorative SciencesAugusta UniversityDental College of GeorgiaAugusta, Georgia

JACqUeline DelASH, DMD, MPHinstructorDepartment of Restorative SciencesAugusta UniversityDental College of GeorgiaAugusta, Georgia

Originally published in: Haywood VB, Delash J. Determining Appropriate Fees for Tooth Bleaching. Inside Dentistry. 2019;15(6): 34-42. Copyright © 2019 to AEGIS Publications, LLC. All rights reserved. Used with permission of the publisher.


cleanup time, can make it difficult to predict an appropriate fee for the process.

to ameliorate this concern, one approach is to combine both “internal” and “external” bleaching treatment. this time-efficient ap-proach involves accessing the tooth internally to clean the pulp chamber, place the barrier, and add the bleaching medicament, as is done in the walking bleach technique (Figure 3); however, after this initial access, the bleaching process is continued from the outside in using a “single-tooth” bleaching tray. Although the

(1.) Bleaching only one arch demonstrates the change to the patient when the bleached maxil-lary arch is compared to the unbleached mandibular arch. (2.) A “single-tooth” bleaching tray allows the bleaching of one tooth without changing the color of the adjacent teeth until the final shade of the single tooth is determined. (3.) The inside of an endodontically-treated tooth must be opened sufficiently to remove pulp debris and any material that is causing discoloration. (4.) A pipe smoker of several years has intrinsic and extrinsic staining, which is very difficult to re-move. (5.) Three months of nightly bleaching using 10% carbamide peroxide in a custom-fitted, non-scalloped, no-reservoir tray successfully removed the nicotine staining. Figures 1, 4, and 5 were previously published in Haywood, VB. Tooth Whitening: Indications and outcomes of Nightguard Vital Bleaching. Chicago, IL: Quintessence; 2007 and reproduced with permission.

fig. 1

fig. 2

fig. 4

fig. 3

fig. 5

addition of “external” bleaching requires an alginate impression, cast, and tray, the time saved by allowing the patient to continue the treatment for as long as is needed at home with-out scheduling weekly chairtime to access the tooth and change the material offsets the cost. this allows the practice to be more time- and cost-efficient and allows the patient to spend less time traveling and visiting the office.

the challenge with the dual “inside and out-side” bleaching approach is choosing the best procedure code and the most appropriate fee.

the dentist should consider selecting “single-tooth internal bleaching” (ie, d9974) for the code and fee because this treatment requires the most chairtime, and then include the cost of making the single-tooth external bleaching tray as a part of that fee without using a sepa-rate code. this approach is more time-efficient and profitable for the office than performing internal bleaching only. After the single-tooth bleaching is completed, which may take 8 to 10 weeks, wait 2 weeks for the shade to sta-bilize and then restore the access opening with a composite in a matching shade. if the single tooth does not fully bleach to match the adjacent teeth, then a lighter-shade compos-ite should be used. sometimes, a stark white, opaque composite material is placed into the most apical third of the access, followed by a matching shade composite in the anatomical area to close the orifice. this composite res-toration requires a different code (ie, d2330) and an additional fee.

in the case of a single dark tooth that was previously endodontically treated but is ad-equately sealed with a composite, there is no need to reenter the pulp chamber in order to bleach if the cleanliness of the pulp chamber can be verified via a radiograph. the normal,

“per-arch” bleaching tray code (ie, d9975) and fee should be applied regardless of whether a single-tooth bleaching tray or full-arch bleaching tray is used to bleach the tooth.

Significant extrinsic and intrinsic Stainingthe extended treatment of nicotine- and tet-racycline-stained teeth requires an approach involving a modified fee. nicotine-stained teeth (Figure 4) require 1 to 3 months of nightly treatment with 10% carbamide peroxide to re-move the soaked-in nicotine stains (Figure 5). tetracycline-stained teeth can require 2 to 12 months of nightly treatment (ie, 3 to 4 months on average) for the bleaching material to enter the dentin and remove most of the tetracycline staining (Figure 6 and Figure 7). due to these unpredictable treatment times, the determi-nation of a fair fee for both the dental office and the patient is best achieved by creating a

“pay-as-you-go” process. the patient pays the normal single-arch bleaching fee using code d9975 and is provided with roughly enough material to bleach one arch for 1 month. during this time, the patient uses a form to record their nights of treatment to determine exactly how long the initially dispensed syringes will last,

inside | restorative

www.insidedentistry.net | June 2019 | inside dentistry 37

which in turn, determines how often the patient will require a refill. the fee for the extended treatment becomes the cost of the materials used per month plus any chairtime needed until the desired shade is reached. the dental office can charge accordingly for the purchase of subsequent bleaching refill kits. Because the treatment time can vary greatly based on each patient’s situation, this method of calculating payment is fair to both the patient and to the dental office. it also allows flexibility for the patient to bleach to the point when the shade stabilizes without further change or to the point when he or she is pleased with the result, tires of the procedure, or no longer wishes to spend further finances on bleaching.

existing Decay ConsiderationsWhen considering bleaching in cases involv-ing existing decay, the treatment may require two different codes and fees. the final shade achieved and the rate of shade change from bleaching is different for every patient. if the patient is interested in bleaching and presents with existing decay that requires a restoration, the dentist cannot reliably predict the final shade of the restoration prior to bleaching. Fortunately, bleaching with 10% carbamide peroxide stops the progression of decay while the bleaching treatment is in process.8,9 With most small carious lesions, the dentist can bleach over the existing decay (Figure 8 and Figure 9), wait 2 weeks for the shade to stabi-lize and the bond strengths to return to normal, then restore the lesion with the appropriate shade of composite.

However, if the decay is deep or the tooth is sensitive, the caries needs to be removed prior to bleaching to avoid further pulpal in-sult (Figure 10). in these cases, the dentist can first place a “protective restoration” (ie, code d2940) with a resin-modified glass ionomer (rMGi), selecting the best possible projec-tion of the final shade (Figure 11). With this protective restoration placed, the patient can then bleach his or her teeth while also minimizing the concern of a pulpal insult or further progression of caries if he or she un-expectedly stops bleaching. if the esthetics of the rMGi need improvement during the bleaching process, a thin layer of resin infil-trate (eg, Optiguard™ surface sealant, Kerr™) can be added to the surface of the restoration to create a glossy and natural appearance (Figure 12 and Figure 13). Upon completion of the bleaching treatment, if the shade of

the rMGi matches reasonably well, and the patient is satisfied with the appearance, then no further treatment is needed. However, if the final bleaching shade does not match the previously placed rMGi, or the surface gloss is insufficient, then the dentist need only re-move the external portion of the rMGi and bond an appropriate shade of composite, leav-ing the remaining rMGi as a base. Although this additional treatment provides the best esthetics and the safest option for deep decay or sensitive lesions, it requires a separate fee and code for the final resin-based composite restoration (ie, d2332).

Thermoplastic TraysFor the maxillary arch, the use of thermo-plastic trays10 can facilitate a reduced fee for patients who require only minimal lighten-ing or who have difficulty with the process of making impressions (Figure 14). teenagers and young adults often have reasonably white teeth but may still have a desire to maximize their tooth shade.11 As opposed to pursuing over-the-counter products,12 it is best for the dentist to provide a proper examination and radiographs to determine a diagnosis for any discoloration.13 Fabrication of a thermoplas-tic tray can be accomplished in a few minutes and bypasses the need for alginate impressions, casts, and a vacuum former. Although the stan-dard single-arch bleaching code is still used, the associated fee can be reasonably reduced be-cause this approach requires less chairtime, no laboratory work, and no impression material. this can provide an excellent way to help some patients achieve their desired level of esthetics without needing to charge the full fee for the traditional bleaching impression/cast. this ap-proach works best on the maxillary arch due to the tongue’s position when swallowing to form the tray. this normal swallowing benefit is not present when attempting a mandibular thermoplastic tray, so the mandibular arch will usually require a traditional impression and tray with a different fee. Just as with tra-ditional, single-arch bleaching, completing one arch at a time is inherently less expensive and can provide the patient with visible results to later determine whether or not bleaching the mandibular arch is desired.

Orthodontic Considerationsthe occurrence of white spot lesions and caries from improper oral hygiene during orthodontic treatment can be significantly


(6.) Tetracycline staining occurs deep in the dentin and is the most difficult stain to remove. (7.) Tetracycline-stained teeth after 7 months of nightly bleaching treatment with 10% carbamide peroxide in a non-scalloped, no-reservoir, custom tray. (8.) Patient with minimal decay that does not need to be restored prior to bleaching because the final shade cannot be determined in advance. (9.) After bleaching over minimal decay, the proper shade can be selected, and the tooth can be restored. (10.) A patient with extensive decay that elicits concerns regard-ing pulpal involvement as well as the restorability of the tooth needs some type of protective restoration prior to the initiation of bleaching. (11.) The caries is removed, and a protective restoration is placed to allow for further bleaching without concern for the advancement of decay if the patient stops bleaching. (12.) A provisional canine restoration made from bis-Acryl does not exhibit the gloss of the adjacent fixed partial denture or teeth. (13.) Placing a compos-ite sealer provides more natural gloss while bleaching is being completed. Figures 6 and 7 were previously published in Haywood, VB. Tooth Whitening: Indications and outcomes of Night-guard Vital Bleaching. Chicago, IL: Quintessence; 2007 and reproduced with permission.

fig. 6

fig. 10

fig. 8

fig. 12

fig. 7

fig. 11

fig. 9

fig. 13

reduced by utilizing bleaching materials.14 Although this approach requires adding an additional fee to that of the orthodontic treatment, the benefits of bleaching while the patient is in an orthodontic appliance can greatly reduce the need for and cost of restorative treatment after the completion of orthodontic therapy. this preventive ap-proach is highly effective because in addition to bleaching the teeth, the bleaching material helps to cleanse the teeth and gingiva from bacteria and plaque during orthodontic treat-ment. Considering the ease of use, cost-ef-fectiveness, and minimal chairtime required, thermoplastic material is ideal for making bleaching trays that fit over orthodontic brackets intraorally (Figure 15). these trays help to fend off white spot lesions and decalci-fication by elevating the intraoral pH, remov-ing plaque, and killing some of the bacteria that cause tooth decay. As the teeth continue to shift during orthodontic treatment, new trays will need to be fabricated approximate-ly every 2 to 3 months, which can add about $400 to $800 to the total treatment costs over a 2-year treatment period. the attraction of this approach is twofold. First, the young pa-tients undergoing orthodontic therapy are motivated to wear the tray because they are bleaching their teeth, and second, the parents are receiving value in their investment via improved hygiene and a reduction in white spot lesions or caries, which subsequently reduces the potential need for costly future restorations that could range from $175 to $250 per tooth. Furthermore, the thermo-plastic trays can be made directly over the orthodontic brackets in the mouth and can also serve as a “sports guard” to minimize bracket damage to the lips and cheeks. the only segment of orthodontics for which this treatment does not apply is when the patient is in cross-elastics. For these patients, inject-ing 10% carbamide peroxide directly onto the brackets will afford some hygienic benefits, as will using a water pick with a 1:1 ratio of water and 3% hydrogen peroxide (Figure 16). in ad-dition, an over-the-counter, 10% carbamide peroxide oral antiseptic supplementary prod-uct (eg, Gly-Oxide® Liquid Antiseptic Oral Cleanser, GlaxosmithKline) can be injected directly onto the teeth and tongue for a 2- to 3-minute cleaning rinse. this product is also used to disinfect and deodorize bleaching trays and many other appliances (eg, occlu-sal guards, oral sleep appliances). Moreover, the manufacturer recommends placing it



on toothbrushes prior to the toothpaste as an adjunct to improve overall oral hygiene. Although Gly-Oxide was the original bleach-ing material, it is too runny for tray bleaching and does not stay on teeth for long periods; therefore, thicker, more viscous materials are indicated for tray use to achieve longer lasting benefits.

Caries ControlOne adjunct to routine caries control is the use of carbamide peroxide with custom trays. this approach can be especially helpful in el-derly patients with dry mouth (Figure 17) or who experience reduced salivary flow from radiation therapy. treatment to control caries with bleaching products should not be given bleaching codes. the appropriate code to use for the tray would be for a “fluoride gel carrier,”

which is d5986, and the appropriate code to use for the material is for “drugs or medica-ments dispensed in the office for home use,” which is d9630. Bleaching products contain-ing urea, such as carbamide peroxide, elevate the pH of the mouth, which stops or slows the process of tooth decay. this change in pH occurs within 5 minutes of tray insertion,15,16 and the pH remains elevated while the trays are in the mouth. in addition, carbamide per-oxide has been shown to kill the bacteria that cause caries.17 Accordingly, the bleaching pro-cess effectively removes the salivary film and plaque layer from the teeth, leading to envi-ronmental control and a reduction in caries. the challenge associated with this approach to caries control is the ongoing cost of the 10% carbamide peroxide. it can be supplied from the dental office in the same manner as it is


fig. 14

fig. 16

fig. 15

(14.) An example of a thermoplastic tray that can be softened with hot water and formed directly in the mouth without making an algi-nate impression and cast. (15.) Thermoplastic tray fabricated directly in the mouth and over the braces with no need to remove the arch wires. (16.) Gly-Oxide, which has a bubbling, foaming action, is injected into the brackets as an adjunct to oral hygiene procedures. (17.) Custom tray used with 10% carbamide per-oxide and worn nightly for caries control in elderly patients. (18.) Patient injects 10% carb-amide peroxide into an area that is difficult to clean with conventional methods.

fig. 17 fig. 18

for the extended treatment approach. Lastly, the patient can pursue over-the-counter 10% carbamide peroxide products for supplemen-tal caries control (Figure 18).

Conclusionin summary, there are many unique situations related to tooth bleaching that require differ-ent approaches to treatment, and these vari-ous approaches necessitate the determination of appropriate treatment codes and related fees. Bleaching is best performed by the dental office after a proper examination, radiographs, and a diagnosis of the cause of discoloration.18 the ability to tailor the treatment to the spe-cific needs and conditions of the patient is a major benefit of having the dental team super-vising ongoing bleaching treatment.

References1. American dental Association. 2018 survey ofdental Fees. AdA Center for Professional success Page. https://success.ada.org/en/practice-man-agement/finances/survey-of-dental-fees. Accessed January 3, 2019.2. Haywood V. tooth whitening is not always tooth


bleaching. Inside Dentistry. 2018;14(2):80.3. Haywood VB, sword rJ. Bleaching tetracyclinestained teeth: considerations and recommendations for treatment. Inside Dentistry. 2018;14(1):38-44.4. American dental Association. Cdt-2017 Codeon dental Procedures and nomenclature. delta dental Website. https://www.deltadentalco.com/uploadedFiles/ProviderFeeschedules/ddCO_Par_Provider_documents/Cdt%202017_Code%20on%20dental%20Proc_nomenclature%20online.pdf. Accessed January 3, 2019.5. Haywood VB. Bleaching a retained primary tooth. Dentistry Today. 2018;37(8):74-77.6. Haywood VB, diAngelis AJ. Bleaching the singledark tooth. Inside Dentistry. 2010;6(8):42-52.7. Freccia WF, Peters dd, Lorton L, et al. An in vitro comparison of nonvital bleaching techniques in the discolored tooth. J Endod. 1982;8(2):70-77.8. Haywood VB. Bleaching and caries control in el-derly patients. Aesthetic Dentistry Today. 2007;1(4): 42-44.9. Lazarchik dA, Haywood VB. Use of tray-applied 10 percent carbamide peroxide gels for improving oral health in patients with special-care needs. J Am Dent Assoc. 2010;141(6):639-646.10. Haywood VB, Caughman WF, Frazier KB, et al.

Fabrication of immediate thermoplastic whiten-ing trays. Contemporary Esthetics and Restorative Practice. 2001;5(9):84-86.11. Greenwall-Cohen J, Greenwall L, Haywood V, et al. tooth whitening for the under-18-year-old patient. Br Dent J. 2018;225(1):19-26.12. Haywood VB, Boyleston e. does “activated char-coal” effectively whiten teeth? Dimensions of Dental Hygiene. 2017;15(12):66.13. Haywood VB. A pre-bleaching exam is vital for op-timum whitening. Inside Dentistry. 2012;8(9):66-68.14. Haywood VB. Orthodontic caries control andbleaching. Inside Dentistry. 2010;6(4):36-50.15. Leonard rH Jr, Austin sM, Haywood VB, et al.Change in pH of plaque and 10% carbamide peroxide solution during nightguard vital bleaching treatment. Quintessence Int. 1994;25(12):819-823.16. Leonard rH Jr, Bentley Cd, Haywood VB. salivarypH changes during 10% carbamide peroxide bleach-ing. Quintessence Int. 1994;25(8):547-550.17. Bentley Cd, Leonard rH, Crawford JJ. effect of whitening agents containing carbamide peroxide on cariogenic bacteria. J Esthet Dent. 2000;12(1):33-37.18. Haywood VB, Bergeron Be. Bleaching and the di-agnosis of internal resorption. Decisions in Dentistry. 2018;4(8):20, 22-25.

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Tray tooth bleaching 2...Everybody’s teeth respond differently, both in how white they get and how quickly that whitening occurs. Tray bleaching expectations include: t Normally