Vital Tooth Whitening: Educating & Marketing

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Vital Tooth Whitening: Educating & Marketing
September/October 2007
Natalie Kaweckyj, RDARF, CDA, CDPMA, COA, COMSA, MADAA, BA
Contemporary Dental Assisting

Abstract

Vital tooth whitening is a regular dental procedure in many dental practices today. The media has a tremendous impact on the dental consumer. As cosmetic dentistry increases in popularity, dental practices should be prepared to meet the cosmetic needs and inquiries of their patients. You, as a dental assistant, are in a unique position not only to educate your patients on vital tooth whitening, but also to market an affordable cosmetic procedure for your dental practice. This article will discuss factors that affect the whitening process, methods of delivery, and up-to-date information that you can pass along to your patients.

Whitening of vital teeth as an esthetic treatment option goes back more than 120 years in the dental literature. There was mention of "lightening the teeth" as far back as the biblical scholars in the third century. Many significant changes have occurred in the materials and methods of whitening, but the constant of patients wanting whiter teeth remains the same. In 1884, hydrogen dioxide was used; 1887 saw the use of oxalic acid; in 1916, fluorosis was being treated with 18% hydrochloric acid solution; and in 1918, use of a bulky, high-intensity light with hydrogen peroxide was introduced. The dentist-prescribed, home-applied technique was introduced in 1968, and reintroduced in 1989 by Haywood and Heymann, the same year the home-use product White & Brite was introduced by Omnii International.1

Whitening products are used by all age groups, with people younger than 30 years of age commonly using one or more whitening products (Table).2 Many patients use over-the-counter (OTC) whitening products in addition to dentist-prescribed or supervised products. Although all current whitening procedures have been proven safe and effective by the American Dental Association (ADA) and the US Food and Drug Administration, continual research results in new products and methods. It is important for dental assistants to be up to date and ready to educate patients with the latest data on "smile opportunities."

Many dental practices include questions on their new patient questionnaire about the patient's satisfaction with their current smile. Some patients may not like their smile line, whereas others may feel that their smiles could be "brighter." Dental assistants can play a unique role in marketing whitening products and procedures in their dental practices, and should be ready to practice what they endorse. By whitening your own smile, you are a walking advertisement for your patients, family, and friends. Dental practices should offer a variety of whitening options for all patient budgets. Whitening is the most conservative treatment for discolored teeth when compared with restorative treatment modalities. As an adjunct treatment to restorative dentistry, tooth whitening can enhance the outcome of the treatment and, in some instances, the decision to proceed with additional esthetic treatment depends entirely on the outcome achieved with whitening.

There are several reasons why teeth discolor. For many, diet and oral habits have a large impact on the brightness of their teeth. Staining foods, such as coffee, tea, cola products, red wine, and dark berries, or the use of tobacco products, play a large role in extrinsic staining. These products characteristically leave yellow to brown stains. Based on clinical studies, 96% of patients with extrinsic stains experience some lightening effect postwhitening.3 For others, certain antibiotics such as tetracycline, conditions such as dental fluorosis, trauma to the dentition, and nonvital endodontically treated teeth result in intrinsic staining. These stains respond to whitening less reliably.3-5 The length of treatment time and the type and amount of material used will vary from one patient to another because of differences in the types of stains being removed and characteristics of the teeth.4,5
Whitening Agents

There are several types of dental whitening agents available. With all agents, stain removal is achieved through oxidation.3-6 The best results are seen in teeth with starting shades in the yellow/yellowÒbrown/orange range.3 Tetracycline-stained teeth tend to lighten, but not brighten. The incisal area of teeth lightens sooner than the gingival third because of the thickness of the enamel and the presence of dentin.3

Carbamide peroxide is one of the most common whitening agents and is available in concentrations from 7% to 35%. Another common form of whitening material is hydrogen peroxide. The supersaturated 35% hydrogen peroxide whitening gels contain 10% to 20% water that rehydrates the teeth throughout the whitening process. Hydrogen peroxide whitening materials are available in concentrations from 6.5% to 35%.3,6 A 10% carbamide peroxide whitening solution is equivalent to a 3% hydrogen peroxide bleaching solution.6 Amorphous calcium phosphate is added to some professional whitening products to aid in posttreatment sensitivity and increase enamel luster.

Factors affecting the whitening process include product composition, concentration, contact time, and delivery method.5,6 Patient factors also play a significant role in the overall outcome of the whitening process. Patient age, baseline tooth color, any dietary or oral habits, and patient compliance all impact final result.3
Whitening Delivery Systems

There are 4 different methods of tooth whitening recognized by the dentistry profession:

* dentist-administered whitening
* dentist-supervised whitening
* dentist-provided whitening
* OTC whitening products

The method of whitening treatment selected will depend on patient priorities, such as time constraints and motivation.

Dentist-administered whitening is performed in the office and is commonly referred to as power bleaching. This method has become very popular and is used by many dental practices. A high concentration of hydrogen peroxide (35% to 50%) and an activating or promoting method, such as heat or laser, is used to enhance and expedite the whitening effect. The heat is delivered with specially designed whitening lamps. Older whitening materials usually require the use of lights to heat-activate the whitening agent, whereas the newer ones do not require heat and instead use a halogen light source, such as a dental curing light or laser.3,5 Most bleaching agents that have been developed for use with light sources include the addition of an activator or colorant to improve light absorption or to reduce heating of the teeth during exposure. Used in-office, gels containing 35% hydrogen peroxide have earned the ADA seal of acceptance for efficacy and safety.3

As with all in-office procedures, dentist-administered whitening requires the dental assistant to be at the chair. In many practices, in-office, dentist-administered whitening procedures are delegated to dental auxiliaries once the dentist prescribes the treatment; however, not all states allow their auxiliary to perform this procedure. Assistants should check their state practice acts.

Each whitening system is unique, but most follow a basic sequence of steps. First, the dentist performs an examination of the oral cavity and prescribes the procedure. Then, the teeth are cleaned with pumice and a protective lip balm is applied generously to the lips with a cotton swab (Figure 1). A lip retractor is then gently inserted and the patient is instructed to bite down lightly. The current shade of the patient's teeth should be recorded using the Vita Classic Shade Guide (Vita Zahnfabrik, distributed in the US by Vident, Brea, Calif, www.vident.com), and photographs should be taken for the clinical record (Figure 2). Some products require the use of 2-inch by 2-inch gauze and a face bib for the procedure, while others do not (Figures 3 and 4). Cotton rolls are inserted in the vestibule and the patient is given protective eyewear. The gingival tissues are air dried and a liquid dam is applied from the attachment of the lip to the enamel until no pink tissue is visible and then light cured to set the material (Figure 5). A pretreatment gel is then applied to the facial surfaces of the teeth on both arches with a disposable brush, followed by the whitening gel in a 1mm to 2mm thickness (Figure 6). The light or laser is then placed close to the retractor and set for 15 minutes (Figure 7). If performing more than one session, excess gel is suctioned or wiped off, pretreatment gel reapplied, and whitening gel applied for another 15 minutes. The procedure is continued until the desired brightness is achieved. Sessions can last from 1 to 3 hours and the number of appointments will vary from patient to patient. After the procedure is complete, the remaining gel and barriers are removed. A postwhitening shade (Figure 8) and photograph should be taken and the patient given posttreatment instructions. Some dental practices provide a complimentary take-home whitening kit to their patients for touch-ups to lengthen whitening results.

Advantages: Dentist-administered whitening treatments provide the greatest results in the shortest period of timeÛbrightening teeth by up to 8 shades in 1 to 5 sessions and lasting for 1 or more years.5

Disadvantages: One disadvantage of dentist-administered whitening is the cost, ranging from $200 to $500 per arch. Another disadvantage is the patients' perceptions of shade rebound. A 2004 study conducted by Tufts University School of Dental Medicine determined that a week after treatment, participants saw an average shade rebound of 2 shades.7 During the procedure the pellicle is removed, reforming in about 24 hours. To help reduce rebound, patients should be advised to refrain from consuming staining products during this time. Tea, coffee, cola, red wine, dark chocolate, blueberries, tobacco products, and anything else that may stain the exposed tooth surfaces should be avoided.

Dentist-supervised whitening is an in-office procedure in which custom whitening trays are fabricated for the patient and loaded with high concentrations of carbamide peroxide (35% to 40%) gel for a period of 30 minutes to 2 hours. The patient either remains in the dental chair or sits in the reception area. Before the whitening procedure begins, the current shade of the patient's teeth is recorded and photographs are taken. The custom trays then can be used in adjunct therapy for whitening touch-ups with a lower concentration whitening agent at home.

Advantages: Dentist-supervised whitening treatments provide good results in a short period of time and patient home compliance is not needed. The trays created then can be used at home with prescribed whitening products or fluoride.

Disadvantages: The biggest disadvantage to dentist-supervised whitening can be the time involved at the dental office for patients who have busy schedules. Other disadvantages are the sensitivity that has been noted with higher concentrations of whitening agents,3,5,8 and the treatment cost that may be slightly more expensive than take-home methods because of the chair time involved at the dental practice.3

Dentist-provided whitening is similar to dentist-supervised whitening, but with lower concentrations of whitening agents applied by the patient at home. This procedure is sometimes referred to as nightguard bleaching. Carbamide peroxide is typically dispensed in 5% to 22% concentrations for home use. A custom set of trays is fabricated for the patient, starting shade and photographs are taken, and the patient is instructed how to use the product. Patients typically wear the trays for 30 minutes to 2 hours, and some agents are available for overnight use.

Other forms of dentist-provided whitening include professional-strength whitening strips and whitening agents for use in generic trays. These products offer a less expensive alternative to the custom-made trays usually provided with dentist-provided whitening options, however, results can vary from patient to patient as some products only cover a limited number of teeth.

Advantages: Dentist-provided whitening treatments provide good results within a relatively short period of time without much in-office time. A variety of concentrations are available to fulfill each patient's specific whitening needs.

Disadvantages: Some sensitivity has been noted with higher concentrations of whitening agents.3,5,8 Dentist-provided whitening requires patient compliance and, for some patients with busy schedules, finding the time to whiten can be a challenge.3

OTC whitening products are in abundance, from toothpastes and mouthrinses with whitening ingredients to whitening gels and strips. All OTC toothpastes help remove surface stains through mild abrasives in the formula. Many whitening toothpastes contain additional ingredients that include soft polishing or chemical agents that provide additional stain- removing success. Some whitening toothpastes contain peroxide, an ingredient found in many whitening products. Whitening gels are peroxide-based gels that are applied with a small brush twice daily for 2 weeks. Whitening strips are very thin, virtually invisible strips that are coated with a peroxide-based whitening gel. The strips are worn twice daily for 30 minutes for 2 weeks. Initial results for both are seen in a few days and final results are sustained for about 4 months.5

Some OTC whitening products, as well as some professional whitening products, contain hydrogen peroxide, a bleaching substance that not only aids in removing surface stains, but also stains found in deeper grooves and crevices.3 Whitening toothpastes only can lighten teeth by 1 shade, whereas in-office whitening procedures can lighten teeth from 3 to 8 shades. All OTC products only affect extrinsic staining.
Posttreatment Instructions

The job of posttreatment instruction usually falls to the dental assistant. Whether the whitening procedure will be performed in-office or through take-home products, patients should be made aware of what to expect during and after treatment. The need for whitening touch-ups will vary depending on the age, diet, and oral habits of the patient and the method of whitening that was used. Whitening is not permanent, and patients who expose their teeth to foods and beverages that cause staining may see the whiteness start to fade in as little as 1 month.3,6

Regardless of the whitening method used, patients should be instructed to brush immediately after consuming staining foods or tobacco products. When brushing is not possible, swishing with water can help rinse away the staining particles. These actions can help keep teeth bright in between treatments. Patients who avoid foods and beverages that stain may be able to wait a year or longer before additional whitening treatments or touch-ups are needed, or as directed by the dentist.

In some studies, patients experienced uncomfortable short-term side effects during tooth whitening, regardless of the method used. Sensitivity to temperatures was the side effect most frequently cited.3 Hydrogen peroxide whitening agents can increase temperature sensitivity in teeth, especially at higher concentrations and when used in conjunction with light or heat activation. This discomfort will eventually subside as the teeth rehydrate.3 For tray whitening methods, patients can wear the trays for a shorter period of time, for example, two 30-minute sessions versus two 60-minute dentist-supervised whitening sessions or whitening every couple of days instead of consecutive days with dentist-provided whitening products, to allow their teeth to adjust.

Some helpful tips you can provide patients include applying a fluoride treatment before or after the whitening treatment to aid with sensitivity and using toothpaste with potassium nitrate. Fluoride foams and gels can be prescribed by the dentist to be used in the custom trays. Recently, specially formulated whitening materials for patients with sensitive teeth have become available. Newer whitening materials have added fluoride, amorphous calcium phosphate, or potassium nitrate to help reduce sensitivity during and after product use, without affecting whitening efficacy.5

The second most frequently cited side effect is gum irritation from the custom trays during at-home procedures. Before patients begin whitening with custom trays, the trays should be fitted in the patient's mouth and any sharp edges that can cut and irritate the gingiva need to be trimmed. Instruct patients who will be performing at-home whitening not to overfill the reservoirs on the whitening trays with the whitening material. Any excess material that squirts onto the surrounding tissue should immediately be wiped away with a cotton swab.
Safety

The major differences in home-use products are the thickening agents, the active ingredients, and the pH of the whitening materials. Thickening agents are used to aid in the adherence of the whitening material to the tooth and carrier, making the product more viscous and reducing the patient's consumption of the whitening agent. Ten percent to 15% carbamide peroxide breaks down into approximately 3% to 5% hydrogen peroxide (H2O2) and 7% to 10% urea.3,7 The H2O2 breaks down into carbon dioxide (CO2) and water, and the urea breaks down into ammonia and CO2.3,7 The body is then able to eliminate these components through regular biological processes.3 Active ingredients have improved to be more efficient with less contact time and less acidity,9 or a more basic pH.6 Before use in vital tooth whitening, carbamide peroxide was used for many years as an oral antiseptic for minor soft tissue injuries or sores.3

Dentist-prescribed whitening is safer and more effective than current OTC products.3 With dentist-prescribed whitening, the dentist prescribes the best treatment program, specifically tailored to patient needs and expectations. If custom trays are indicated, the dental health team will provide the patient with properly fitted trays, unlike OTC trays that may interfere with closure of the jaws, allow leakage of whitening material, and irritate the soft tissues of the mouthÛall leading to less effective whitening.
When Whitening Is Not Recommended

The American Academy of Pediatric dentistry discourages bleaching for anyone in a mixed dentition, and often anyone younger than 16 years old, because the pulp chamber is enlarged.4 Teeth whitening under this condition could irritate the pulp, causing sensitivity.4 Whitening also is not recommended in pregnant or lactating women.

Patients with gum disease or teeth with worn enamel should be discouraged from undergoing whitening procedures because whitening products do not penetrate dentin.3 Areas of concern should be treated before undergoing any whitening procedure because the whitening solution can penetrate into existing defects and cause sensitivity. Whitening procedures also will not work on exposed roots because the enamel layer is missing.3

Resin composite materials used in crowns, veneers, bonding, and bridges do not whiten.3 Any whitening procedure should be done before the placement of restorations. Patients with numerous restorations, which would result in uneven whitening, may have better results with composite restorations, veneers, or crowns rather than using a whitening system.3

Patients who have unrealistic expectations may be disappointed with their results.10 As previously mentioned, yellowish teeth respond well to bleaching, brownish teeth respond less well, and grayish or purple-stained teeth may not respond to whitening at all.3 Blue-gray staining caused by tetracycline is more difficult to lighten and may require up to 6 months of home treatments or several in-office appointments to lighten.3 Smokers should be made aware that their results will be limited unless they refrain from continued smoking, particularly during the whitening process.
Educate and Market

There is one main advantage for our patients when they choose to incorporate vital tooth whitening into their lives: brighter and more youthful smiles. As whitening technology evolves with new delivery systems and improved products, it is important for dental assistants to stay ahead of mass marketing to best answer patient questions and concerns. If your dental practice does not currently offer in-office whitening, your dental team may be missing out on potential revenue. Through continued media exposure, more and more of your patients will expect in-office whitening options as part of standard dentistry. If your practice currently offers whitening options, market these treatment options to your patientsÛit is a wonderful way to involve the entire dental team.

References

1. Haywood VB. Nightguard vital bleaching. Dent Today. 1997;16:86-91.
2. Oral Health and the US Population. Chicago, Ill: American Dental Association Survey Center; 2005.
3. Pesun IJ, Madden R. A review of the current status of vital bleaching. Northwest Dent. 1999;78:25-33.
4. American Academy of Pediatric Dentistry Council of Clinical Affairs. Policy on bleaching for child and adolescent patients. Pediatr Dent. 2005-2006;27(7 Reference Manual):46-48.
5. Giniger M, MacDonald J, Ziemba SL, et al. The clinical performance of professionally dispensed bleaching gel with added amorphous calcium phosphate. J Am Dent Assoc. 2005;136:383-392.
6. Ziemba SL, Felix H, MacDonald J, et al. Clinical evaluation of a novel dental whitening lamp and light-catalyzed peroxide gel. J Clin Dent. 2005;16:123-127.
7. Zekonis R, Matis BA, Cochran MA, et al. Clinical evaluation of in-office and at-home bleaching treatments. Oper Dent. 2003;28:114-121.
8. Gerlach RW, Sagel PA. Vital bleaching with a thin peroxide gel: the safety and efficacy of a professional-strength hydrogen peroxide whitening strip [published erratum appears in J Am Dent Assoc. 2004;135:156]. J Am Dent Assoc. 2004;135:98-100.
9. Giniger M, Spaid M, MacDonald J, et al. A 180-day clinical investigation of the tooth whitening efficacy of a bleaching gel with added amorphous calcium phosphate. J Clin Dent. 2005;16:11-16.
10. Deliperi S, Bardwell DN, Papathanasiou A. Clinical evaluation of a combined in-office and take-home bleaching system. J Am Dent Assoc [serial online]. 2004;135: 628-634. Available at: jada.ada.org/cgi/content/full135/5/628. Accessed Jun 20, 2007.