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					IR sept haywood redo 17&18       17/11/04   11:56 am       Page 1




           CLINICAL




       Why, when and how to whiten your patients’ teeth
        World expert Van Haywood puts you on track
      One year on, Nicola             Why is it that you tend to
                                      prefer to whiten your
                                                                            (pea-sized) of 10% carbamide
                                                                            peroxide (CP) in each tooth
                                                                                                               necessary when bleaching
                                                                                                               teeth? What is your
      Kramer once again               patients’ teeth using at-home         mould of the tray, and inserts     perspective on over-the-
                                      tray bleaching rather than in-        the tray. They press the           counter (OTC) pharmacy-
      interviewed Van                 office power bleaching?               material-filled tray against the   bought bleaching kits?
      Haywood to find out             In-office bleaching requires one
                                      to four visits to achieve the
                                                                            teeth to spread the material.
                                                                            Then they sleep with the tray in
                                                                                                               My concern for off-the-shelf
                                                                                                               products is that a proper
      more about aesthetic            same level of whitening as at-        place, or wear it about four       examination has not been
                                      home bleaching. Hence the cost        hours per day. Whitening of the    performed to determine the
      smile design                    and effort of in-office bleaching     teeth generally takes two to six   cause of the discolouration, and
                                      tend to outweigh the benefit.         weeks of nightly wear,             whether a patient is a good
                                          Each visit can be one to two      although some teeth may            candidate for bleaching.
                                      hours of time. Since the dentist      lighten in a matter of days, and      Some discolourations of the
                                      does not know if the patient          other discolourations take         teeth are indicative of pathology
                                      will require multiple visits, it is   months.                            (abcessed teeth, dental decay,
       Van B Haywood, DMD, is         hard to predict a fee that is fair                                       internal resorption) and need
       Professor in the               to both. The patient must be          Is dental supervision              treatment other than bleaching
       Department of Oral             willing to pay for multiple
       Rehabilitation, School of      weekly visits should they be          This 16-year-old girl has completed orthodontics, but is not happy
       Dentistry at the Medical       needed. Generally, the darker         with her smile due to her yellow teeth
       College of Georgia. He is a    the teeth, the more visits
       member of numerous             required, and not all teeth will
       organisations, including the   successfully bleach.
       American Dental                    With at-home bleaching, if a
       Association, the               treatment time longer than two
       International Association of   to six weeks is needed, such as
       Dental Research, the           for nicotine staining or
       American Academy of            tetracycline staining, or when
       Esthetic Dentistry and the     the teeth are very dark, then the
       American Academy of            only requirement is additional
       Restorative Dentistry. In      material, which is much less
       1989, he co-authored the       costly. At-home bleaching is
       first publication in the       very easy and very safe. It
       world on nightguard vital      whitens all the teeth, where in-
       bleaching (at-home tray        office only whitens the six or
       bleaching using 10%            eight anterior teeth. The in-
       carbamide peroxide) with       office bleaching requires
       Dr Harald Heymann, which       isolation techniques to avoid         A smile analysis reveals both the maxillary and mandibular teeth
       formally introduced the        burning the gingival, which can       show in a full smile. However, to encourage patient compliance,
       technique to the profession    be quite uncomfortable. The           and measure the difference in colour change over time, only the
                                      staff must take great care not to     top arch will be treated initially
                                      burn themselves or the patient,
                                      which requires constant
                                      supervision. Post-operative
                                      sensitivity is greater with
                                      in-office bleaching as well.

                                      Can you explain the process
                                      involved in tray bleaching?
                                      An impression is made of the
                                      teeth and gums. This is used to
                                      generate a stone replica of the
                                      patient’s teeth. A thin, clear,
                                      flexible tray is fabricated on the
                                      stone cast. This is trimmed and
                                      fitted to the patient. The
                                      patient applies a small amount

      16                                                                                                                Irish Dentist September 2004
IR sept haywood redo 17&18           17/11/04   11:56 am      Page 2




      (the bleaching actually hides the                                                    A closer            teeth (or milk teeth) do not
      indication of disease). Other                                                        examination         need bleaching. However, I do
      patients have crowns and                                                             demonstrates        a lot of mixed dentition
      fillings which will not change                                                       that the teeth do   bleaching, when the central
      colour, so if they bleach their                                                      not match the       incisors and lateral incisors are
      teeth they have a ‘pinto pony’                                                       whites of her       erupting, and they are
      look, where the crowns and                                                           eyes. This          markedly yellow or have
      fillings are dark and the natural                                                    indicates the       fluorosis staining. The teeth
      teeth are white. Other fillings                                                      patient would       respond very rapidly, the
      may show through the teeth                                                           benefit from        children do great, and the
      after bleaching and require                                                          bleaching           benefit to their confidence
      replacement.                                                                                             is enormous.
           After a proper examination
      and diagnosis, the patient can                                                                           Is there a difference in
      use a number of treatment                                                                                procedure when bleaching
      options, some of which may                                                                               the white or brown
      include OTC products.                                                                                    discolourations associated
      However, the quality of the                                                                              with excessive fluoride
      OTC product is determined by                                                                             ingestion?
      the company, so I would                                                                                  Brown stains are removed
      beware of unknown sources.                                                                               about 80% of the time by
                                                                                                               bleaching, so bleaching is the
      If you consider that a patient                                                                           first choice for brown
      is a candidate for whitening,                                                                            discolourations. White stains
      how do you broach the                                                                                    do not go away (and may
      subject with them?                                                                                       actually get lighter during the
      The challenge is how to inform                                                                           process and regress at the end),
      them of their option without                                                                             but the background of the
      insulting them. I ask them if                                                                            tooth can often be lightened to
      they are happy with their smile,                                                                         mask the white stain. If
      or if there is anything they                                                                             bleaching is not sufficient, then
      would like to change. There                                                                              abrasion of the white area,
      may be a question on the                                                                                 possibly with coverage by
      medical history that asks if                                                                             composite, may be required.
      they want to bleach or lighten
      their teeth.                                                                                             In what situations is an
          If they come in for a tooth                                                                          extended whitening course
      cleaning, they need to see                                                                               likely to be needed?
      posters and pamphlets                                                                                    Tetracycline-stained teeth can
      describing the process. I also                                                                           take two to six months of
      verbally note the shade of the       A close up of the teeth demonstrates the baseline colour. Her       nightly treatment with 10%
      patient’s teeth to my dental         teeth are shade A4 on a Vita Shade guide, which is a dark yellow    carbamide peroxide in a
      assistant, and tell them to note                                                                         custom-fitted tray. Nicotine
      in the chart that: ‘If ever the      going to pick the shade of the     look. Hence if their teeth       stains generally take one to
      patient is interested in             restoration, which will not        are darker than the whites       three months of treatment.
      lightening their teeth, they are a   change, it is important that we    of their eyes, they              Other stains, from ageing to
      good candidate’. Having staff        determine the overall shade for    will look better with            foodstuffs to genetic
      who have bleached their teeth is     the teeth.                         bleaching.                       discolourations, vary in the two
                                                                                                               to six week range.

                     Since everything in dentistry (and the

           ‘
                                                                                                               For those who are concerned
                                                                                                               about the safety of
                     world) hinges on the morals and ethics of                                                 nightguard safety bleaching,
                                                                                                               what would you say to them?
                     the person involved, there are certainly                                                  There is a long history of safety




                                                                                              ’
                                                                                                               with 10% carbamide peroxide
                     issues in tooth whitening that occur                                                      prior to bleaching, including
                                                                                                               use in infants for throat
                                                                                                               infections, youths with
      often a good visual aid, as are         If patients ask whether         Is it appropriate to consider    orthodontics and elderly
      photographs in the reception         they would look better,            children as candidates for       patients. The baby is given 10
      room of patients.                    then I evaluate the whites of      bleaching?                       drops of 10% carbamide
         On the other hand, if I am        their eyes. When the colour        The only children with primary   peroxide every two hours for
      doing some restorative work, I       of the teeth and the whites        teeth we have bleached is when   seven to 10 days to heal the
      always ask them if they want to      of the eyes match, that is a       primary centrals were darkened   throat infection. This is far
      bleach their teeth. Because I am     very photogenic and natural        by trauma. Otherwise, primary    more than is swallowed

      Irish Dentist September 2004                                                                                                            17
IR sept haywood redo 17&18        17/11/04     11:56 am     Page 3




       CLINICAL




      After 8 days of treatment with 10% carbamide peroxide in a           The difference in colour change between the top and bottom teeth
      custom fitted tray (non-scalloped, no reservoirs), the patient has   is apparent to the patient in her full smile and encouraged her to
      experienced significant lightening. Treatment will continue until    continue nightly treatment. The patient is excited about the outcome
      either the teeth no longer change colour or the whites of the eyes   and has experienced little problem with wearing the tray at night,
      a re matched                                                         although she has skipped a few nights due to lifestyle issues

      during bleaching.                (and the world) hinges on the      or gum it sells incredibly well,     patient or the research design
          Prior to bleaching, the      morals and ethics of the           whether or not it works.             than the material (assuming the
      Food and Drug Administration     person involved, there are         Consumers are spending a lot         material is a good product).
      in the US had recognised         certainly issues in tooth          of money on products that have           Since shade guides used to
      the use of 3% hydrogen           whitening that occur.              no research or clinical papers to    measure bleaching changes are
      peroxide and 10-15%                  Probably the most              demonstrate efficacy. The claims     not linearly spaced, there is no
      carbamide peroxide as            discouraging practice is the       made in advertisements do not        good way to compare
      ‘generally                                                                     have support but          reasonable products in studies
      recognised                                                                     play on the               with similar shade changes.




                    ‘
      as safe’ for             My concern for off-the-shelf                          emotional needs of            Another issue with
      oral use for                                                                   the consumer to be        companies is their using
      the life of              products is that a proper                             beautiful and             research tools that are available
      the person.                                                                    accepted.                 only to their company, where
      More                     examination has not been                                 Another issue for      no other researchers can
      importantly
      in the
      bleaching
      arena now,
      we have 10-year recalls on the
      first group of patients treated
      with two to six weeks of
                               performed

                                       over-the-counter products sales.
                                       Companies have discovered
                                       that if they place the word
                                                                             ’       the manufacturer is
                                                                                     making claims of a
                                                                                     certain number of
                                                                                     shade changes and
                                                                          superiority over another
                                                                          bleaching product (both of
                                                                          which work), when the change
                                                                                                               duplicate their experiment or
                                                                                                               support their claims because
                                                                                                               they cannot use those tools.
                                                                                                                   One issue for the dentist is
                                                                                                               charging too much for a
                                                                                                               procedure, rather than a fee
                                                                                                               reflective of the time and cost to
      bleaching, and 7.5-year recalls  ‘whitening’ on their toothpaste    is more dependant on the             the practice, in an attempt to
      on the patients using six-month                                                                          make a lot of money quickly.
      tetracycline-stained bleaching.  The patient received a custom tray fabricated from an alginate          Additionally, claiming
          In both groups using 10%     impression, and a carbamide peroxide product, Dentalwhite, from         superiority of their technique by
      carbamide peroxide, there are    a European company (Victoria Dental Products Limited, Victoria          use of some special light or
      no detrimental effects to the    House, Greenock, Scotland PA15 1HD; tel: 00 44 1475 807 116).           material, or charging the
      teeth, body or health, and the   The initial treatment uses 10%CP in a syringe. The additional           patient for in-office without
      benefit for the minimal cost     syringes are 16%CP, which can shorten treatment time somewhat           mentioning the other less-costly
      and minimal risk is very good    if sensitivity is not a problem                                         and possibly more appropriate
      and long lasting. There are                                                                              bleaching options, is
      several other studies supporting                                                                         inappropriate.
      this statement.                                                                                              There is a place in the
          Other routinely performed                                                                            bleaching arena for most all
      dental procedures, including a                                                                           delivery forms that have been
      prophylaxis (tooth cleaning),                                                                            shown to work, but that choice
      do more harm to the teeth, as                                                                            is driven by patient conditions,
      does drinking juices and colas,                                                                          their desires and lifestyle,
      than bleaching.                                                                                          financial resources, and
                                                                                                               reasonable expectations. The
      As with any elective                                                                                     cost-benefit and risk-benefit of
      treatment, there are clearly                                                                             any procedure should be
      some ethical issues involved                                                                             considered carefully in making
      in tooth whitening. How do                                                                               the final decision after a proper
      you see these issues?                                                                                    examination and diagnosis of
      Since everything in dentistry                                                                            the discolouration. Z

      18                                                                                                                Irish Dentist September 2004

				
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