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Update on Teeth Whitening
Advances and techniques that every practice can incorporate
Dental patients seem to be increasingly preoccupied with health, fitness, and beauty. As they diet and exercise their way to more youthful appearances, they also may realize that one of the hallmarks of looking youthful is having a bright, beautiful smile. Studies have shown that an attractive smile can influence society’s judgment of a person’s facial attractiveness and personal characteristics.1 When asked, many individuals will say that the smile is what they notice first in a person. Psychological studies repeatedly confirm that when people feel secure about dental appearances, they develop confidence and well being, and are better perceived by others.2
These days, “whiter teeth” is one of the most popular esthetic requests from dental patients, and tooth-whitening procedures are well-tolerated, noninvasive approaches to achieving this goal.3,4 This article explores the latest whitening advances and techniques that can be incorporated into a dental practice, leading to greater prosperity. The whitened, beautiful smiles of patients become walking endorsements.
Teeth whitening, although seemingly new in dentistry, has existed since the 17th century, when people would visit their barbers for haircuts and tooth whitening. Barbers would pull teeth and perform whitening by filing down the teeth and applying nitric acid, causing them to whiten. This must have been fairly painful and harmful to the teeth, and is a far cry from where dentistry is today.5 In 1884, hydrogen peroxide was introduced for teeth bleaching, and in 1918, the use of high-intensity lights was added to accelerate the whitening process.6 At that time, cosmetic dentistry was in its infancy, and teeth whitening was widely unknown and rarely performed. It wasn’t until the 1980s that in-office teeth whitening started to become popular and 1990 when over-the-counter whitening products became available due to the use of carbamide peroxide.7 As a result, the dental landscape was transformed by the introduction of a plethora of whitening products with advanced systems and technology. The predictable and sought-after results helped to usher in the age of the much-desired “Smile Makeover.”
How many times have dentists met patients who said that they tried tooth whitening, but it just didn’t work for them? Or maybe they achieved a whiter shade, but it just wasn’t as white as they anticipated. People see celebrities on TV, with bright-white smiles from veneers, and think that they can achieve those same results by simply doing an in-office whitening session. Dentists must manage these patients’ expectations, tell them how dentists can help to achieve what they envision, and present the various whitening options, once they have become educated on the various treatments available.
It is very important to take the time to perform a pre-whitening exam to:
-- Ensure that the patient is a good candidate for successful whitening
-- Identify old bonded restorations or crowns and bridges that won’t whiten, and
-- Inform the patient of any whitish decalcifications inherent in the enamel that may whiten disproportionately
Patients should be advised that these white spots may become temporarily prominent after whitening treatment because the teeth are more desiccated. The spots will start to fade as the teeth rehydrate. Failure to discuss white-spot response and advise patients about the post-whitening temporary prominence will result in the patients blaming the procedure for causing these spots to appear. Pre-procedural identification of these decalcifications (which may have developed for various reasons, including malformation of the enamel during tooth development and/or the acid breakdown of food debris from poor home care) is vital to managing patient expectations.
Any unsightly white spots that remain after whitening can always be prepared out and replaced with tooth-colored bonding that blends with the newly lightened shade. Restorative work in the esthetic zone, in this author’s opinion, should be performed after whitening is completed and the color stabilized. In addition, any bonding should be delayed for about 2 weeks after whitening is completed to achieve the best long-term results, as the teeth will rehydrate over the subsequent 24 to 48 hours and not be as white as they were immediately after the whitening treatment.
Understanding the Options
Which is a better way to whiten teeth—using an in-office or at-home whitening system? In-office whitening is a faster alternative for achieving that brighter smile, with a high degree of predictability, and is proven to be safe to use and well-tolerated.8,9 This method has been popular for patients whose free time is limited or who want instant gratification. Additionally, in-office whitening eliminates patient compliance issues with using the whitening agent in a tray daily for several weeks. Some products combine the use of in-office whitening with at-home whitening products to maximize patient result (eg, Philips Zoom WhiteSpeed, Philips Oral Healthcare, www.philipsoralhealthcare.com; Lumibrite, DenMat, www.denmat.com; Opalescence®, www.ultradent.com; KöR Whitening, KöR Dental Technologies, www.evolvedental.com). The home trays, when used beforehand, can help condition the teeth for more dramatic in-office results. They can also be used for a period after an in-office session to continue the whitening process, or to help lock in the shade that was achieved.10 It is recommended to keep the custom trays for periodic touchups either before a big event or to use several times per year to maintain the shade that the dental team attained. The custom trays can also double as desensitizing trays, and can be used either before an in-office session or after to minimize discomfort.11 Some individuals may choose not to wear a custom tray if they are more hypersensitive or prone to gag reflex. In those instances, an additional in-office session may become necessary to achieve the desired result. Conversely, for those whose teeth are too sensitive to undergo an in-office procedure, the custom home trays allow for the patient to be in complete control, using the right concentration of peroxide over a comfortable duration.
Patient compliance is usually better at night, although some people may not be able to tolerate sleeping while wearing these trays. Night use affords the individual maximum benefit from each application because of the longer exposure time and diminished salivary flow. However, some people may need to reduce the duration of their treatments as a result of sensitivity or personal preferences. For these individuals, daytime wear is recommended for 15- to 30-minute intervals. Patients who experience gingival irritation with daily use of tray whitening are recommended to switch to an every other day routine to minimize or eliminate these issues.
Patients should be advised that if their teeth are discolored by the natural process of aging or through heavy consumption of foods and beverages that are more likely to stain (such as red wine, coffee, and vegetable and berry juices), the prognosis for a beautiful, youthful smile is excellent. Individuals with yellower teeth will typically have more dramatic results than those with grayer teeth. Individuals with more even toned layers of enamel will have much more predictable results than those with tetracycline stains or white-spot formations.3 When veneers are considered to improve esthetics and the patient has darker teeth, whitening as part of the treatment plan will assist in esthetic changes of the underlying tooth structure and better masking.
Whitening Sensitive Teeth
First determine that the patient’s sensitivity is not stemming from some other underlying problem that would need to be addressed more urgently (eg, a large cavity, fractured tooth). If no urgency exists and the sensitivity is due to tooth grinding or clenching, gingival recession, exposed root surfaces, or other sources, then precautions must be taken to make the patient as comfortable as possible while whitening (ie, shielding any exposed root surfaces to protect from the whitening gels). A sensitivity-relief fluoride toothpaste or gel with 5% potassium nitrate can be prescribed for use before and after treatments. The author recommends replacing regular toothpaste with a 1.1% neutral sodium fluoride paste for 2 weeks prior to whitening as part of the sensitivity protocol. Desensitizing solutions (eg, Relief® ACP gel, Philips Oral Healthcare) with amorphous calcium phosphate has been shown to be effective desensitizers, and can be applied either in the office (before and/or after the in-office whitening treatment) or placed in a custom whitening tray at home, instead of the whitening gel.11-13 When planning in-office whitening in patients with reported sensitivity, it is recommended that the patient use desensitizing gels and toothpastes for 2 weeks before whitening is performed.
Some patients may experience sensitivity throughout the treatment; others may not experience any sensitivity. Usually, any sensitivity one may experience ceases within 24 hours from the termination of treatment. Older patients’ teeth have less sensitivity due to the nerves within the tooth becoming less prominent and migrating farther away from the outside surfaces. People with gingival recession and root exposure may have more sensitivity when the bleaching agents come into contact with those exposed surfaces.
Whitening Resistent Teeth
A number of people have more resistance to the effects of teeth whitening. In-office whitening may require multiple visits to get optimal results, and in many cases, it is recommended to follow the in-office whitening with home tray whitening.14,15 Whatever the reason, the teeth of many of these individuals will still whiten quite well using the following technique. The patient’s teeth are conditioned on the first visit and receive slow, time-released exposure during the at-home wearing of the customized whitening trays. After several weeks of home whitening, the patient is then given another full in-office whitening session to induce the desired effect..
Smile whitening is no longer a luxury reserved for the rich and famous. Well-tolerated, noninvasive, and affordable approaches are available to help patients whiten their teeth and reap the psychological and social-emotional benefits of a whiter smile.
1. Jornung J, Fardal O. Perceptions of patients’ smiles: a comparison of patients’ and dentists’ opinions. J Am Dent Assoc. 2007;138(12):1544-1553.
2. Hester R. The therapeutic effects of smiling. In: Abel MH, ed. An empirical reflection on the smile. Mellen studies in psychology. Vol 4. Lewiston, New York: Edwin Mellen. 2002:217-253
3. Strassler HE. Professionally dispensed vital tooth bleaching – an update on the newest whitening materials. Inside Dentistry. 2010;6(3):68-73.
4. Li Y, Dorfman W, Gerlach R, Fischer D, Tooth whitening: a roundtable discussion. The AACD Monograph. vol. 2. American Academy of Cosmetic Dentistry; 2005.
5. Kugel G. A study of tooth whitening: Safety, efficacy and mechanism of action [thesis]. Siena, Italy: Tufts University;2004.
6. De Moor R, Vanderstricht K. The use of the KTP laser, an added value for tooth bleaching. J Oral Laser Appl. 2009;9:219-226.
7. Li Y. The quest for whiter teeth: a continued demand in aesthetic dentistry. The AACD Monograph. vol 2. American Academy of Cosmetic Dentistry; 2005.
8. Lee SS, Kwon SR, Arambula M, et al. Assessment of whitening efficacy of two in-office professional bleaching regimens. J Dent Res. 2013;92(Spec Iss B):1139.
9. Li Y. Toxicological considerations of tooth bleaching using peroxide containing agents. J Am Dent Assoc. 1997;128(Suppl):31s-36s.
10. Matis BA, Cochran MA, Wang G, Eckert GJ. A clinical evaluation of two in-office bleaching regimens with and without tray bleaching. Oper Dent. 2009;34(2):142-149.
11. Haywood VB, Caughman F, Frazier KB, Myers ML. Tray delivery of potassium nitrite-fluoride to reduce bleaching sensitivity. Quintessence Int. 2001;32(2):105-109.
12. Tung MS, Eichmiller FC. Dental applications of amorphous calcium phosphates. J Clin Dent. 1999;10(1 Spec no):1-6.
13. Tay LY, Kose C, Loguercio AD, Reis A. Assessing the effect of a desensitizing agent used before in-office tooth bleaching. J Am Dent Assoc. 2009;140(10):1245-1251.
14. de Silva Gottardi M, Brackett MG, Haywood VB. Number of in-office light activated bleaching treatments needed to achieve patient satisfaction. Quintessence Int. 2006;37(2):115-120.
15. Zekonis R, Matis BA, Cochran MA, et al. Clinical evaluation of in-office and at-home bleaching treatments. Oper Dent. 2003;28(2):114-121.
A | Opalescence® PF
Opalescence® PF take-home whitening gels from Ultradent have a patented sticky, viscous formula that keeps the gels in the tray longer for sustained whitening power. Its unique combination of potassium nitrate and fluoride decreases sensitivity while also strengthening enamel and preventing cavities. A water content of 20% helps prevent dehydration and relapse.
B | Crest® Whitestrips® Supreme
Crest® Whitestrips® Supreme from Procter & Gamble offers the highest concentration of hydrogen peroxide available in a professionally dispensed take-home whitening system. These portable, ready-made strips deliver a consistent, controlled dose each time and are only available only through dental professionals.
C | KöR® Whitening
KöR® Whitening, developed by Dr. Rod Kurthy, is widely accepted as the world’s most effective tooth-whitening system. Super-effective enough to whiten even tetracycline stains, KöR is mainly used on everyday cases because any patient asking for teeth whitening expects genuinely white teeth. KöR also offers a 100% money-back satisfaction guarantee.
D | Venus White® Pro
Venus White® Pro from Heraeus Kulzer is a high-performance take-home whitening system formulated for enhanced whitening with shorter wear times. Venus White Pro’s two-in-one formula combines carbamide peroxide and potassium nitrate to decrease sensitivity often associated with bleaching. It is available in 16%, 22%, and 35% carbamide peroxide strengths.
E | Pro-SYS™ Professional
Tooth Whitening System
The Pro-SYS™ take-home whitening kit by Benco Dental delivers a high-performance system for a more radiant smile. Available starting June 1 in carbamide peroxide or hydrogen peroxide formulas, Pro-SYS supports a wide range of uses. To eliminate sensitivity, it also features potassium nitrate.
F | LumiSmile™ White
LumiSmile™ White from DenMat is available in 32%, 22% and 16% carbamide peroxide concentrations, and features reduced sensitivity, real peppermint oil flavoring, and 18 months of shelf life without refrigeration. The addition of glycerin, water, and potassium nitrate was designed to minimize dehydration of the teeth and improve patient comfort.
g | Zoom! WhiteSpeed
Using blue LED technology that emits the
optimal light spectrum, Philips’ Zoom! WhiteSpeed light-activated whitening system accelerates and enhances whitening results with no compromise to safety. The Zoom! WhiteSpeed offers different intensity settings so that clinicians may ensure patients’ comfort while still providing the results they expect.
h | Perfecta® REV!®
Perfecta® REV!® 14% hydrogen peroxide take-home tooth whitening from Premier Dental Products Company gives patients the white smiles they desire in only 15 minutes once a day. REV! is water-based to hydrate teeth as it whitens to avoid thermal sensitivity naturally. Patients will love the short wear-time and added bonus of the Finishing Rinse.
i | Niveous
Niveous from Shofu contains a stabilized blend of 25% hydrogen peroxide for bright, white smiles that meet the demanding patients’ esthetic needs. Conveniently packaged in unit-dose ampules, Niveous requires no mixing. Niveous offers enhanced whitening results with “Booster” brushes and a new formula of Niveous Liquid Dam with improved handling.