NewsletterReinforce your role as a trusted dental professional
Christopher Baer, DMD
The dental team is a trusted source of information related to both the health and appearance of patients’ teeth, including when teeth are discolored. According to the American Dental Association (ADA), the most critical factor in the tooth whitening process is proper examination prior to initiating bleaching treatment.1 During routine visits, dental team members may identify patients who are interested in whitening their teeth and conduct an in-office evaluation to determine the cause of discoloration as well as the whitening treatments—if any—that are appropriate for their individual case.
The dental professional should also determine the specific cause(s) of discoloration, as that will impact both the recommended treatment and the patient’s expectations for its success.
After determining the cause of the discoloration and before recommending a specific treatment, practitioners will take into account whether other factors are contraindications for treatment, including allergies to materials, tooth sensitivity, willingness to follow treatment, and financial considerations.2,3
It is essential to manage patient expectations for individual results along with the timetable for achieving them. The type of discoloration, patient’s age, and the concentration and duration of use of the chosen agent will impact the outcome.
During the consultation, therefore, dental professionals should discuss all pertinent issues, including whether bleaching is an appropriate option for this condition in this patient; whether other treatments should be performed prior to or in conjunction with the whitening procedure to improve esthetics or minimize side effects; and which method that best meets the patient’s needs, including financial and lifestyle considerations.4
The ADA describes four categories of tooth whitening/bleaching treatment methods: professionally applied (in the dental office); dentist-prescribed/dispensed (patient home-use); consumer-purchased/over-the-counter (applied by patients); and other non-dental options such as treatments or kits sold in non-dental retail settings, such as mall kiosks, salons, spas, and cruise ships.1
In-Office Treatment
There is little doubt that the most effective whitening treatments are those delivered by the dental team in the office. With the dental team in complete control, there is no learning curve or need for compliance by the patient, and the team can monitor results, focusing on specific teeth and terminating or modifying treatment if the patient experiences side effects. Dental teams should inform patients at the outset that they will likely need between two and six treatments—the cost of which should be specified—to achieve satisfactory results, and that the wait time for shade stabilization is at least 2 weeks and can be as must as 6 weeks for higher concentrations of material.5
Prescribed At-Home Treatments
Treatments that are prescribed by the dentist but applied at home by patients using a custom-fitted bleaching tray are less expensive than in-office treatments, but require more time to produce optimal results (Figure 1 and Figure 2). They may involve use overnight or for an 8-hour time period using 10% carbamide peroxide (CP) or for a shorter time period using a much stronger agent—25% to 38% CP or 10% hydrogen peroxide (HP).2 Evidence supporting home treatment includes a study showing that 5 days of at-home whitening with 10% CP overnight (8 hours) yielded tooth whitening comparable to a 1-hour in-office treatment with 25% HP. In addition, after in-office treatment, most request continuation of tooth whitening at home.6
Over-the-Counter Treatments
Among the over-the-counter whitening products found through consumer platforms are systems composed of whitening strips, paint-on brushes, rinses, toothpastes, dental floss, chewing gums, and combinations of these components, some of which include whitening trays. Their bleaching agents may be similar to those offered by dental practices but their efficacy varies greatly and depends on their method of placement and contact with the teeth.2 There is evidence that whitening strips can be effective for the removal of intrinsic stains and that whitening toothpastes, gum, and floss can aid in the removal of extrinsic stains.7
All tooth whitening methods involving the use of chemical agents are subject to side effects, which vary in severity from one patient to the next.
Soft-Tissue Effects
Higher concentration whitening agents can produce a chemical “burn” when they contact soft tissues, causing tissues to turn white and the patient to experience mild discomfort. This discomfort and change in color disappear once the tissues rehydrate. In the office, strategies for protecting tissues include the use of a rubber dam or other protective barrier during treatment.8
Hard Tissue—Tooth Sensitivity
It is difficult to predict which patients, other than those who have experienced sensitivity in the past, will suffer this discomfort after whitening. Therefore, it is essential to inquire before commencing treatment, and patients can be tested for the likelihood of sensitivity with a blast of compressed air.9
An ADA position paper expresses a number of concerns related to “non-dental whitening venues,” including “the long-term safety of unsupervised bleaching procedures, due to abuse and possible undiagnosed or underlying oral health problems,” and cautions that the rate of adverse events from use or abuse of home-use over-the-counter products is likely under-reported to the U.S. Food and Drug Administration Medwatch system.1
There are many good reasons for all dental professionals—even those who don’t offer in-office whitening themselves—to be well versed in tooth whitening procedures and products, including their risks and benefits, and to actively support their patients’ desire to improve the color of their teeth. By inquiring about this concern and screening patients for medical sources of discoloration, they can reinforce their role as a trusted provider of oral health information while being poised to help patients avoid ineffective treatments or deal with uncomfortable side effects.
The author received an honorarium from Heraeus Kulzer.
1. Tooth whitening/bleaching: treatment considerations for dentists and their patients. ADA Council on Scientific Affairs. September 2009 (revised November 2010). www.ada.org/sections/about/pdfs/HOD_whitening_rpt.pdf. Accessed April 5, 2013.
2. da Costa J. The tooth-whitening process: an update. Compend Contin Educ Dent. 2012; Nov/Dec. http://www.cdeworld.com/courses/4633. Accessed April 15, 2013.
3. Strassler HE. At-home vital tooth bleaching. Inside Dentistry. February 2011. www.dentalaegis.com/id/2011/02/at-home-vital-tooth-bleaching-a-current-status-update-on-professionally-dispensed-and-otc-methods. Accessed April 5, 2013.
4. Haywood VB. Pre-bleaching exam vital for optimum whitening. Compend Contin Educ Dent. 2012:33(1). www.dentalaegis.com/cced/2012/01/pre-bleaching-examination-for-optimum-tooth-whitening. Accessed April 15, 2013.
5. Haywood VB. In-office bleaching: Lights, applications, and outcomes. Current Practice. 2009;6(4).
6. da Costa JB, McPharlin R, Paravina RD, Ferracane JL. Comparison of at-home and in-office tooth whitening using a novel shade guide. Oper Dent. 2010;35(4):381-388.
7. Demarco FF, Meireles SS, Masotti AS. Over-the-counter whitening agents: a concise review. Braz Oral Res. 2009;23 Suppl 1:64-70. 2012. www.dentalaegis.com/ida/2012/10/professional-tooth-whitening-a-minimally-invasive-esthetic-treatment. Accessed April 8, 2013.
8. Marshall K, Berry TG, Woolum J. Teeth whitening considerations. Inside Dental Assisting. January/February 2012. www.cdeworld.com/courses/4575. Accessed April 15, 2013.
9. Swift E. Tooth sensitivity and whitening. Compend Contin Educ Dent. 2005;26(9 Suppl 3):4-10.
Christopher Baer, DMD
Private Practice
Denver, Colorado
