Navigating the “Whitening Maze” Assessment and Clinical Protocol

INTRODUCTION TO THE DENTAL PATIENT (IDP III)

Dorothy Vannah, M.Ed., RDH, CDA Director :The Simulation Learning Center

Associate Professor: Diagnosis & Health Promotion 2015

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At-Home Tooth Whitening

Also known as night guard bleaching, vital tooth whitening.

Noninvasive dental procedure that uses “bleaching” agents to whiten dark or discolored teeth with living pulp.

Most requested service

Opalescence PF 10% Lowest sensitivity whitening product on the market

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Dental Whitening Agents: Composition and Chemical Make-Up

Active ingredient common to ALL Whitening products: Carbamide peroxide or Hydrogen peroxide

Gel base: Propylene glycol/glycerin and water

Thickening agent: Carbopol

Additives: Potassium nitrate or Fluoride

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Hydrogen peroxide - Carbamide peroxide

Hydrogen peroxide –The ↑ the concentration the more rapid the lightening effect. Day-time , shorter wear time

Carbamide peroxide - Is weaker than hydrogen peroxide, added thickening to allow a prolonged exposure to the whitening agents. Night-time , longer wear time

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Composition cont.

Hydrogen Peroxide concentration is equivalent to three times the comparable Carbamide Peroxide concentration.

10% Carbamide peroxide ≈ 3% Hydrogen peroxide (H2O2)

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Dental Whitening Agents: Composition

Carbamide peroxide, the active ingredient most widely used is available in gel concentrations that range from 10% to 22%.

Having multiple concentrations from 10% to 22% allows you to customize the bleaching program to each patient’s specific needs.

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How Whitening Works

Oxidation is believed to be responsible for the observable whitening

In the presence of saliva, Carbamide peroxide breaks down into hydrogen peroxide and urea, which then degrades into water an oxygen; materials commonly found and readily disposed of in the body.

10% = 7% urea, 3% hydrogen peroxide 15% =10% urea, 5% hydrogen peroxide 20% = 13% urea, 7% hydrogen peroxide

2 H2O2 = 2 H2O + O2

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Oxygen enters the enamel and dentin and diffuses to areas containing the discolored substances.

The structure of the tooth is not altered; only the tooth is made lighter and whiter.

O2 O2 O2 O2 O2

Mode of Action

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Mode of Action

Free radical passes through enamel and dentin, breaking up the carbon chains

Color is “oxidized,” causing lightening effect

Tooth structure is unchanged

Only chroma and value are altered

H 2O2 - Hydrogen Peroxide breaks down into H20 - water and O - oxygen free radical

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Why do we whiten?

To remove stains and discolorations due to:

Natural factors

Congenital factors

Systemic factors

Pharmalogical factors

Trauma factors, etc.

To make people feel better about themselves:

Look younger

Improve confidence

Smile more

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Types and Nature of Stains/Discolorations

External:

Ingestion of chromatogenic drinks (colas, coffee, tea, wine)

Tobacco (cigarettes, chewing)

Aging (thinning of enamel)

Micro cracks in the enamel, Internal

Drugs (tetracycline, fluoride)

Trauma Systemic conditions

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Types and Nature of Stains/Discolorations

Severe jaundice in infancy

Dental caries

Presence of Restorations / Endodontic treatment

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Types and Nature of Stains/Discolorations

Multiple variables affect the outcome of the whitening procedure. Dependent upon the following factors:

Cause or type of discoloration or stain

Brown stains response well 80%

Grey stains, less response

White stains behave differently – White “spot”cannot be removed, the background is lightened, white “spot” is less noticeable

Degree or intensity of the discoloration or stain

1 of 4

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Success Rates /Considerations

Multiple variables affect the outcome of the whitening procedure as well: Selection and strength of whitening agent Length of exposure of the teeth to the whitening

agent Selection of Whitening technique Cooperative/compliant patient

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Success Rates /Considerations

Mild cases of tetracycline staining and fluorosis have a higher success rate with whitening than do moderate to severe cases.

Yellow, orange or light brown stains are treated more successfully 80%

Blue-gray stains are more difficult to remove.

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Home Whitening

10% for 10 Nights

BEFORE AFTER

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Moderate to advanced tetracycline stains

Before

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Intrinsic/Extrinsic Staining

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Color chart

Before whitening procedure

After completion

The effects of most whitening systems last between 3 - 5 years.

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Tooth Whitening -Intrinsic stains (From Roberson T, et al: Sturdevant’s art and science of operative dentistry, ed 4, St Louis, 2002, Mosby.)

Before After

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Composite Restoration

Before whitening procedure

After completion

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Tetracycline Staining

Before whitening procedure

After completion

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Moderate to advanced tetracycline stains

Before

After Treatment may take 2-6

months

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WHITE SPOTS

Possible causes:

Decalcification Excessive fluoride during tooth formation

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Contraindications to Tooth Whitening

Pregnant or lactating women

Children and Adolescents/ Judicious Use Only

- The American Academy of Pediatric Dentistry discourages:

full arch bleaching, mixed dentitions

– permanent teeth/single teeth

Restorations / Replacement

- Tooth colored

- Porcelain

- Planned restorative procedure within 2 weeks/ ↓ bonding strength, color match

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Contraindications cont.

Exposed root surfaces (may not have optimal results)

Hypersensitivity (Treat the sensitivity issues beforehand)

Sensitivity or allergy to components of the whitening agent

Unreasonable personal expectations

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How Long Will It Take?

Yellow/Brown 1-2 weeks

Blue/Grey twice as long

Tetracycline several months

(~ 5% of population will not whiten)

10% carbamide peroxide = 3% hydrogen peroxide 35% carbamide peroxide = 12% hydrogen peroxide

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Potential Side Effects of Tooth Whitening: Thermal hypersensitivity

To ↓ sensitivity while wearing the tray:

Shortening duration or frequency of treatment

↓The solution concentration

Alternate whitening solution with potassium nitrate or sodium fluoride, a desensitizing agent directly in the tray

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Assessing Sensitivity:

SOLUTION

trim tray off soft tissue, instruct patient proper dosage, discontinue bleaching until wounds heal.

Shortening duration or frequency of treatment

↓The solution concentration

Alternate whitening solution with potassium nitrate or sodium fluoride, a desensitizing agent directly in the tray

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Potential Side Effects of Tooth Whitening: Gingival Irritation

Strength of Whitening solution Due to contact with the whitening solution or an ill-

fitting tray. Trim the tray away from the gingival for a better fit Consider using a trayless whitening method

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What to look for in a Home Whitening System?

Sustained Released Formula Nighttime whitening - material stays active for 8-10 hours by adhering to

oral soft tissues, thereby permitting continued antimicrobial action resisting dilution by salivary action or gingival crevicular fluid.

Near Neutral pH (6.5)

Heavy, Viscous, Sticky Gel Tray containment of the material gingival irritation

Product Containing 20% Water Minimizes dehydration sensitivity

Product with Desensitizers

Reservoirs or No Reservoirs

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Opalescence Carbamide peroxide Tooth Whitening gels

Four concentrations – 10%, 15%, 20%, 35%

Allows clinician to customize a treatment for specific patient needs

All contain desensitizing agents

.3% potassium nitrate, 0.11% w/fluoride

Opalescence PF 10% Lowest sensitivity whitening product on the market

Patented, sustained-release formula

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Opalescence PF 10% (cont)

Sticky gel consistency- Gel holds tray in place

Less wasted gel, Limited material swallowed by patient

Three flavors - Encourages patient compliance

Soft tray with reservoirs

ADA accepted (10% original)

20% water content - Minimizes dehydration that can lead to sensitivity

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Frequently Asked Questions

Will my teeth lighten 8-12 shades?

Will my teeth be sensitive? How long does tooth

whitening last? Will tooth whitening affect

the enamel?

Studies on the Opalelsence PF product line show that use of TresWhite or Opalesence PF minimize sensitivity and provides anti-caries benefits as well as increases enamel microhardness. It improves the overall enamel health.

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Frequently Asked Questions

Will my teeth lighten 8-12 shades?

Will my teeth be sensitive? How long does tooth

whitening last? Will tooth whitening affect

the enamel?

Studies on the Opalelsence PF product line show that use of TresWhite or Opalesence PF minimize sensitivity and provides anti-caries benefits as well as increases enamel microhardness. It improves the overall enamel health.

Patient Preparation AXIUM – CASE NOTES

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Patient Preparation

Patient Assessment: Complete medical history, oral cancer screening, dental and

periodontal exam, FMX

Review current oral hygiene routine, note the surface of the tongue

CAMBRA- Caries Management by Risk Assessment

Occlusal evaluation

Evaluate the presence of existing hypersensitivity

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Patient Preparation (cont)

Develop a Treatment Plan

Identify existing restorations, crowns, bridges that need replacing

Select appropriate method of whitening and provide education on whitening product and procedure

Determine tooth shade guide and take photographs

Obtain Informed Consent

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Patient Preparation

Patient Instructions - Review Instructions for Use

Procedures Prior to Whitening - Photographs with shade guide - Scaling and Prophylaxis - Restorative procedures/removal of decay

Planning for Maintenance and Follow-Up

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Clinical Protocol

Eliminate extrinsic stain, plaque and calculus

Deplaque tongue

Evaluate for additional preventive and clinical treatment for sensitivity applying topical fluoride varnish to prevent sensitivity during whitening

Take impressions for custom whitening trays

Reappoint for: delivery or trays and follow-up for evaluation of whitening procedure

Documentation in AxiUM

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Screen Shot – AxiUm

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Screen Shot – AxiUm

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Screen Shot – AxiUm

PATIENT INSTRUCTIONS

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•Patients should be told beforehand: • Existing composites will not lighten • Limit intake of foods,beverages, and smoking that will stain the teeth during treatment

Restorative Considerations

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PATIENT INSTRUCTIONS Nighttime schedule

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PATIENT INSTRUCTIONS Daytime schedule

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Only place a small bead of gel in each tooth impression towards the labial surface of the patient’s tray

Delivery: Gel Dispensing Protocol

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Delivery

Have the patient place the tray in their mouth.

Using a finger or a toothbrush gently run along the edges and remove excess gel.

Instruct the patient on wear time and possible side effects.

Re appoint for follow up.

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Delivery

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Custom Whitening Tray in Place

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If you are planning any cosmetic dentistry, it is strongly recommended that you start by whitening the teeth first. After all, why match a new smile to old coffee stains!

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Haywood V.B. Bleaching and Caries control in Elderly patients Aesthetic dentistry today October 2007 Volume1 Number 4 Haywood V.B. Bleaching and Caries control in Elderly patients Aesthetic Dentistry Today October 2007

Volume/ Number 4 Primarily the indication for caries control for ageing patients, those with physical handicaps or patients in nursing homes for which conventional brushing and flossing is not proving effective.

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Chemotherapeutic Approach Root Caries may be minimized by:

10% Carbamide Peroxide (preferred) in custom tray overnight Remove plaque

Elevate pH

Kills Lactobacillus bacteria

Used in combo with Chlorohexidine –Strep Mutans

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Rampart Root Surface Caries

Associated with ↓ in salivary flow due to both aging, ↑ side effects of medications

Decline in Health

Loss of manual dexterity

Side Effects of Whitening: Teeth become whiter, mismatched existing restorations

Technique to be used for the life of the patient

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Haywood V.B. Bleaching Children’s teeth: Questions and Answers The GAGD Explorer

(Georgia Academy of General Dentistry ) Summer 2006

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Bleaching Children’s Teeth

How young can the child be for bleaching? 10-14 year old range with permanent teeth present

Are there concerns for sensitivity in the young tooth? We know that peroxide goes through the enamel and

dentin to the pulp in 5-15 minutes, which is apparently the cause for sensitivity.

NO. possibly the good blood supply, large apices and resiliency of children allows sensitivity not to be a problem.

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Bleaching Children’s Teeth

What about safety to the child from swallowing the product? 10% carbamide peroxide is used in new born infants, 10

drops in their throat every two hours for 7-8 days, to treat candidias or thrush.

Urea peroxide used in 1800’s to stop caries in children with pitted teeth.

10% carbamide peroxide as a rinse,(Glyoxide0, in orthodontic patients during 3 years treatment to prevent white spot lesions.

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Bleaching Children’s Teeth

The strongest position for safety is that of the American Dental Association’s seal of approval.

4 have the ADA seal: Rembrandt by DenMat (Johnson & Johnson)

Platinum by Colgate Oral Pharmaceuticals

Opalescence by Ultradent Products Inc.

NiteWhite by Discus Dental.

Fabrication of a Custom Whitening Tray

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Fabrication of Custom Tray

Alginate impressions is the first step

Pour up stone model

Cut model in a horseshoe shape, removing palatal and tongue areas

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Fabrication of Custom Tray Creating reservoirs

Use LC Block-Out to create reservoirs on model (0.5mm layer).

Do not apply block out material to incisal edge, interproximal areas, or next to the gingival margin.

Doing so will allow bleaching material to escape from the whitening tray

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Light cure block out material for 30 seconds

Fabrication of Custom Tray Creating reservoirs

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Fabrication of Custom Tray

Vacuum Former : heating element melts the plastic sheet and then suctions it to the stone model

Thermoplastic sheets .035 mm

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Fabrication of Custom Tray

Put tray sheet in vacuum form unit and allow to heat until tray sags 2.5 inches

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Trimming

Remove gross tray material with Utility Vinyl Cutters For detailed trimming, use the Ultra-Trim scissors

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Flame Burnishing

Flame polish edges of tray and adapt with wet finger to smooth rough edges that could irritate gingiva