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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

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:

Gel base:

Propylene glycol/glycerin and water

Thickening agent:

Carbamide peroxide or Hydrogen peroxide

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 patients 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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Mode of Action

O2

O2

O2

O2

O2

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.
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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:

1 of 4

Cause or type of discoloration or stain

Brown stains response well 80%

Grey stains, less response

White stains behave differently White spotcannot be


removed, the background is lightened, white spot is less
noticeable

Degree or intensity of the discoloration or stain

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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


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BEFORE

AFTER

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: Sturdevants 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 illfitting 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.
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Patient Preparation
AXIUM CASE NOTES

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

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PATIENT
INSTRUCTIONS

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

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PATIENT INSTRUCTIONS
Nighttime schedule

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PATIENT INSTRUCTIONS
Daytime schedule

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Delivery: Gel Dispensing Protocol

Only place a small bead of gel in each tooth impression towards the labial
surface of the patients tray
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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
Haywood V.B. Bleaching and Caries control in Elderly
October
2007 Volume1
4
patients Aesthetic
DentistryNumber
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 Childrens teeth:


Questions and Answers The GAGD Explorer
(Georgia Academy of General Dentistry ) Summer
2006

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Bleaching Childrens 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 Childrens 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 1800s 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 Childrens Teeth

The strongest position for safety is that of the


American Dental Associations 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.

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Fabrication of a
Custom Whitening
Tray

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

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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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Fabrication of Custom Tray


Creating reservoirs

Light cure block out material for 30 seconds

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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

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