Achieve Whitening Expectations
Combining in-office and at-home treatment maximizes results
Shannon Pace Brinker, CDA
The rise in popularity of tooth whitening can be attributed, in part, to its cost-effectiveness and immediate results. To meet the tooth whitening demands of patients, a variety of bleaching solutions and techniques have been developed, enabling shorter and more convenient treatments, more predictable results, and a reduction in side effects.1
A 22-year-old female patient presented to the office with the chief complaint of discolored teeth. She had tried an over-the-counter whitening strip system, but was disappointed with the outcome and wanted fast results for an upcoming event.2 During the examination of the patient, the key clinical parameters evaluated were good periodontal health, minimal gingival recession, and the absence of decay.
Diagnosis and Whitening Analysis
The diagnosis was yellowing of the teeth, caused by the patient's habits of consuming tea and soft drinks. Following diagnosis, a complete whitening analysis was performed.3 A treatment plan was selected that involved in-office whitening followed by at-home whitening using custom trays.
Impressions and Tray Fabrication
Impressions of the patient's dentition were made with a vinyl polysiloxane alginate alternative material (xantasil®, Kulzer) (Figure 1). This material accurately captures intraoral details in impressions that are free of voids, bubbles, or other imperfections. Next, to facilitate the same-day fabrication of whitening trays, study casts were poured using a fast‑setting dental stone (Modern Materials®, Kulzer). After the casts were trimmed to a horseshoe design with no palate or tongue space, a soft, vinyl bleaching tray was fabricated using a vacuum forming machine. The whitening trays were then trimmed and set aside for delivery on the day that the in-office whitening procedure was completed.
A cheek retractor was used to provide a full view of the anterior and posterior teeth, and preoperative photos were taken. Utilizing a shade guide (VITA classical A1-D4®, VITA Zahnfabrik), the patient's initial shade of B1 was verified (Figure 2). A resin-based, light-cured gingival barrier (Venus White Max, Kulzer) was applied at the contour of the gingival tissue to protect the tissues by preventing contact between the whitening gel and the gingiva (Figure 3). To keep the patient comfortable and the field free of saliva, a suction device (Ivory Releaf, Kulzer) was inserted to help reduce saliva flow (Figure 4).
After the gingiva was protected, in-office whitening was performed using a 38% hydrogen peroxide solution (Venus White Max, Kulzer), which facilitates significant whitening results with a start-to-finish time of about an hour. In addition to the shorter treatment time, the inclusion of potassium nitrate in the composition leaves patients with less postoperative sensitivity when compared with other in-office systems.
In addition, no light is needed when whitening with Venus White Max, and the syringe-to-syringe mixing technique prior to application guarantees stability and full strength for each in-office use.4 Once mixed, the whitening gel was applied to the teeth (Figure 5).
After 15 minutes, the whitening gel was removed from the teeth utilizing suction from a high volume evacuator to avoid splatter (Figure 6). Additional whitening gel was then reapplied for three more 15-minute applications. The total whitening procedure can be performed in either three or four 15-minute treatments. After the final application, all whitening gel was removed from the teeth. The Ivory Releaf, gingival barrier, and cheek retractor were also removed, and the patient was given a final rinse. Following the procedure, a shade analysis revealed that the patient had achieved the bleached shade OM3 (Figure 7).
At-Home Whitening Treatment
After the in-office whitening procedure, the custom home trays were tried-in for proper fit and postoperative instructions for at-home whitening were given to the patient. Based upon the patient's history of sensitivity, a 16% carbamide peroxide solution was chosen that contained potassium nitrate to decrease sensitivity during bleaching (Venus White® Pro, Kulzer). The patient was instructed to wear the trays once per day for 3 to 4 hours.
Following 7 days of using the custom at-home trays, the patient returned to the office for evaluation and further shade change had occurred. The final bleached shade achieved was OM2 (Figure 8). The patient noticed marked improvement and was very pleased with the final outcome.
Tooth whitening is a growing market, and more and more people are investing their time and resources into achieving whiter smiles. Vital tooth whitening is an effective treatment modality that can significantly change the appearance of teeth. Patient satisfaction has been demonstrated after the use of professionally dispensed bleaching treatments. Their conservative nature and little, if any, associated risk make them an important part of an any esthetic dentistry restorative plan.
About the Author
Shannon Pace Brinker, CDA
Academy of Chairside Assisting
Virginia Beach, Virginia
1. Hasson H, Ismail A, Neiva G. Home-based chemically-induced whitening of teeth in adults. Cochrane Database of Syst Rev. 2006;18(4):CD006202.
2. Demarco FF, Meireles SS, Masotti AS. Over-the-counter whitening agents: a concise review. Braz Oral Res. 2009;23(Suppl 1):64-70.
3. Haywood VB. The "bottom line" on bleaching 2008. Inside Dentistry. 2008;4(2):82-89.
4. Torres CR, Souza CS, Borges AB, et al. Influence of concentration and activation on hydrogen peroxide diffusion through dental tissues in vitro. Scientific World Journal. 2013 Sep 18;2013:193241.