Whitening Tooth-Whitening by zhangyun


              Tooth-W hitening
                                              Kristy Menage Bernie, RDH, BS
       he ever-expanding tooth-whitening options and number of individu-
     T als who have chosen this economic, safe, and most effective means
                                                                                               TABLE 1

     of smile enhancement have created demand for maintenance proto-
     cols. Maintaining the results of professionally administered or dispensed
     whitening will vary from patient to patient and largely depend upon daily
     habits. As a result, most recommendations for maintaining results are
     based upon basic oral hygiene science combined with new products
     that can assist with maximizing whitening. A review of considerations both
     pre- and post-whitening—in addition to maintenance options—arms
                                                                                                   Classification of
     clinicians with critical information to assure maximum tooth-whitening
     results and client satisfaction.                                                          s INTRINSIC
                                                                                                  Deep internal
     How Does Stain Occur?                        ingestion, or 2) extrinsic staining,             Tetracycline exposure
     Maintenance of whitening results             which is due to exposure to liquids,             Excessive fluoride ingestion

     begins long before the final whiten-         or tobacco (Table 1). Intrinsic stain-       s EXTRINSIC
     ing treatment or application is com-         ing is a result of an accumulation              Exposure to:
                                                                                                    Liquids (eg, coffee, tea, colas)
     pleted. Careful evaluation of patient        of internal and external staining
                                                                                                    Tobacco products
     habits and type of staining, in addi-        that    has   occurred      over   years.
     tion to the whitening treatment              Additionally, with age, the enamel
     rendered, determines the potential           thins at the cervical areas, allowing
     longevity   of   whitening    results.       more dentin to show through,
     Staining can be classified in terms          making the teeth appear dark and            agents. Regardless of the type
     of the type of staining: 1) age-relat-       even dingy.                                 of staining, once whitening is
     ed or deep internal (ie, intrinsic)                 A more dense intrinsic stain is a    achieved, the maintenance of the
     staining, as seen with tetracycline          result of systemic exposure to a            result will be the same.
     exposure or excessive fluoride               specific agent such as tetracycline
                                                  or fluoride. While these stains are         How Does Whitening Work?
                                                  more challenging to whiten, the             Whitening agents can be divided
                                                  desired outcome can be accom-               into peroxide-based agents and
     Kristy Menage Bernie, RDH, BS, is
                                                  plished with longer treatment times         those products that do not contain
     Director and Cofounder of Educational
     Designs, a dental hygiene consulting         for dispensed at-home whitening,            peroxide. Peroxide-based products
     service. She is immediate and past           more chairside treatments, or a com-        and treatments are effective in
     president of the California Dental           bination of both. An extrinsic stain is     achieving a wide range of shade
     Hygienists Association and is a dele-        an external accumulation on the             enhancement and are available by
     gate on the council of Member Services
                                                  enamel surface that has resulted            professional application in-office or
     for the ADHA. She can be reached at
                                                  from exposure to staining-related           through professional dispensing for

34     The Journal of Practical Hygiene
daily use. Hydrogen peroxide is uti-      mogenic (staining-related) material
                                                                                                            TABLE 2
lized in both professionally applied      from being absorbed by the newly
and dispensed products, while car-        whitened enamel surfaces.
bamide peroxide is typically used             As the shade stabilizes and
for extended wear on a daily basis.       teeth rehydrate, patients should
    When peroxide-based agents            avoid foods or liquids that stain
come into contact with tooth sur-         (Table 2) for the first 24 to 48 hours
faces, they break down and remove         following chairside treatment. This         Maximizing In-Office
or dissolve stain within both the         assures that maximum whitening                   Whitening
dentin and enamel surfaces through        will be realized and must be effec-                   Results
oxidation. Both external and internal     tively communicated to clients.            s Apply 1.1% neutral sodium
stains deep in the tooth structure are    Additionally, staining-related habits,       fluoride immediately following
impacted by these agents. As this         such as use of tobacco, should be            the last application of whiten-
                                                                                       ing material.
process continues, the enamel surface     avoided for obvious reasons. This
                                                                                     s Tell patients to avoid foods and
become more opaque and reflects           may also provide an excellent
                                                                                       liquids that stain, such as curry,
light, making the teeth appear whiter     opportunity to initiate a tobacco-           ketchup, mustard, red wine,
and brighter. Whitening results can be    cessation program. Maintenance               cola, coffee, and tea.
seen immediately with professionally      options at this point are identical to     s Make impressions for a
administered systems and within as        those of patients who have chosen            custom tray for future touch-
little as a week or so with profession-   professionally dispensed, take-home          up procedures.
ally dispensed take-home products.        whitening products.                        s Reappoint for tray delivery
Nonperoxide-based products will               For those patients who prefer            and final shade analysis.
                                                                                       Also, reappoint for additional
be useful in maintaining results and      take-home options, professionally
                                                                                       chairside application and/or
will minimize or reduce extrinsic-        dispensed products are an important          |at-home use for further
based stains.                             part of a successful and long-               whitening.
                                          term result. These systems typically       s Instruct the patient on daily
Maintenance of Professionally             involve a custom-fitted tray and             maintenance.
Administered and                          either hydrogen or carbamide per-
Professionally Dispensed                  oxide solutions. Results are usually
Whitening Results                         seen within weeks and can be main-
Maintenance for chairside whitening,      tained through a variety of products.     unproven means to deliver the
which may utilize a light or laser        Patients should be informed about         whitening agent through boil-and-bite
source to accelerate the whitening,       staining-related agents and advised       mouth trays. In addition, many OTC
begins at the whitening appoint-          that daily exposure to such agents        options have not undergone the
ment. During a chairside treatment,       can reverse whitening results over        rigorous testing seen with profession-
immediate whitening occurs. The           time (Table 3).                           ally dispensed products. Recently the
first step to maximizing results is to                                              American Dental Association (ADA)
initiate tooth rehydration through the    Over-the-Counter Options:                 issued a statement that OTC perox-
application of a 1.1% neutral sodium      Peroxide-Based Products                   ide-based whitening products would
fluoride solution. This is easily         It is important to educate patients       not be eligible for consideration
applied after the last application of     regarding over-the-counter (OTC)          for the ADA Seal of Acceptance.
the whitening agent and should            whitening products as they are not        According to the ADA’s Statement on
remain on the teeth for five minutes.     always reliable. This is due to many      the Safety and Effectiveness of Tooth
The application of fluoride will not      factors, such as acidic and runny solu-   Whitening Products, “Only those
only begin the rehydration phase,         tions which are easily swallowed          products   dispensed    through      the
but is also useful in preventing chro-    and may damage enamel, as well as         dental office are considered for the

                                                                                         September/October 2003                35
 Maintaining Tooth Whitening

      TABLE 3                                  Over-the-Counter Options:                 fit is extrinsic stain reduction/
                                               Nonperoxide-Based Products                removal versus true “whitening.”
                                               Nonperoxide-based products are
                                               available in a variety of options from    What to Recommend
                                               toothpaste to chewing gum and             Regardless of the system utilized to
                                               everything in between. There are          achieve tooth-whitening results, main-
                                               two main categories of nonperox-          tenance strategies are similar. To
            Patient Education
                                               ide-based means, mechanical and           assure maximum results, patients
        Pointers for Maintaining               chemical, which work on extrinsic         should be provided with touch-up
              W h it e n i n g                 stain.   Essentially   any     device     whitening        material       as     needed.
                                               designed to remove, reduce, or            Professionally dispensed take-home
      s Avoid staining-related habits,
                                               eliminate plaque provides value           products assure the quickest results
        such as use of tobacco
                                               in keeping extrinsic stain to a           possible. The general consideration is
                                               minimum. Automatic toothbrushes,          that for every week it took to achieve
      s Use drinking straws with
        chromogenic beverages, such
                                               as well as auto-flossers, are of          the final result, one wear time/expo-
        as coffee, tea, and colas.             particular interest as they have been     sure is required to rewhiten the denti-
      s Utilize automated toothbrushes         proven effective in extrinsic stain       tion. For example, if it took three
        and whitening toothpastes.             reduction and even elimination            weeks of nighttime wear to whiten
      s Practice thorough daily oral           with certain technologies. Manual         the teeth to the designated degree
        hygiene, including use of              toothbrushes and specialty floss          of whiteness, then three nights of
        interdental aids, irrigators, and      also may be useful in minimizing          wear should restore the whitening
        tongue deplaquing and/or
                                               interproximal stain accumulation.         result. Daily methods to minimize
                                               Patients should be instructed to          extrinsic stain are beneficial for main-
      s Seek regular dental hygiene
                                               utilize these devices on a regular        taining whitening results as well
        care to maintain periodontal
        health, to keep staining to a          basis, and recommendations for            as maximizing oral health between
        minimum, and to determine the          specific products should be based         touch-ups or to extend the results.
        need for whitening touch-up.           on   client   preference,    lifestyle,
                                               and habits.                               Conclusion
                                                    Other mechanical functioning         The role of the dental hygienist as
                                               products include whitening tooth-         the patients’ educator begins almost
                                                                                         immediately. By setting realistic out-
                                               pastes and chewing gum. Toothpastes
                                                                                         come expectations and by providing
     Seal because professional consulta-       are helpful mechanically and even
                                                                                         information on available methods
     tion is important to the procedure’s      chemically, in some instances, by
                                                                                         to extend the whitening results,
     safety and effectiveness.”                keeping extrinsic stain from forming.
                                                                                         the patients’ will realize long-term
         As a result, patients should not      Additives to toothpaste and chewing       benefits for this inexpensive, safe,
     use these products to maintain            gum reportedly coat the teeth so that     and effective means to enhance and
     whitening results without the express     staining cannot occur. Care should        improve their smile.
     recommendation of their dental pro-       be taken in recommending certain
     fessionals. Instead, patients should be   chewing gum products as they call         References
     counseled to request a shade analysis     for multiple pieces throughout the         1.   ADA Statement on the Safety and
                                                                                               Effectiveness of Tooth Whitening Products.
     at preventive appointments to deter-      day for twenty minutes of chewing          2.   Moran JM, Addy M, Newcombe RG. A
                                                                                               Comparative Study of Stain Removal with
     mine the need for possible touch-up       at a time. Regardless, these options            Two Electric Toothbrushes and a Manual
     utilizing professional products. This     only benefit extrinsically-based stain          Brush. J Clin Dent 1995;6(4):188-193.
                                                                                          3.   McInnes C, Johnson B, Emling RC, et al.
     consultation, in addition to use of       and do not provide the intrinsic                Clinical and Computer-Assisted Evaluations
     nonperoxide-based products, assures       stain removal seen with professional            of the Stain Removal Ability of the Sonicare
                                                                                               Electric Toothbrush. J Clin Dent 1994;
     the longest-lasting results possible.     products; therefore, their main bene-           5(1):3-8.

36     The Journal of Practical Hygiene

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