Dental hygienist Steven Scannell discusses his teeth whitening experience and offers his top tips.
When you look at global teeth whitening trends, there is no doubt that the demand is still there and growing. White teeth have become a symbol of good oral health and self-care habits. I feel privileged to be able to help my patients achieve the improved appearance of their teeth.
In an effort to encourage more dental professionals to get into the whitening business, I was recently asked to share my teeth whitening tips. Fear of the unknown is very natural. But I hope I was able to reassure my peers that bleaching can make an important addition to practice. It is quite easy to implement if the right protocols are put in place. The right products will also give you real peace of mind.
Identifying patients who are suitable for treatment
It is important to understand that whitening is not for everyone. You need to assess whether patients should undergo bleaching and if so, what treatment will work best for them.
I would not advise pregnant and lactating women to whiten their teeth. The same applies to people who drink too much alcohol and/or smoke, people who are immunocompromised, people who are allergic to any of the ingredients in whitening products, and people under 18 years of age.
Smokers may undergo whitening, but should be advised to reduce or stop to make the whitening effects useful.
The right whitening system
In our practice, we use Philips Zoom Daywhite and Nitewhite products for home imaging. For those patients who want quick results, we offer a Zoom in-chair procedure so we can offer a range of treatment options for our patients’ varied lifestyles.
Hydrogen peroxide (H2THE2) The gel used in Daywhite penetrates through the enamel and as it is absorbed, the peroxide breaks down into water and oxygen molecules. These oxygen molecules break the carbon double bonds of the chromophore stain molecules, making these molecules appear colorless.
I tend to use Daywhite for patients who have a lighter initial shade. Also, those who find it difficult to wear discs at night and want quick results. Daywhite treatment takes about 30 to 90 minutes a day for two weeks.
Zoom Nitewhite gel contains carbamide peroxide, which breaks down into hydrogen peroxide and urea. As it has a slower release rate, it can be used when a longer contact time with the teeth is possible.
Nitewhite is available in two strengths: 10% and 16% carbamide peroxide. The recommendation is to use 10% for two to four hours and 16% for four to six hours. This treatment option tends to be for patients with darker shaded teeth who can tolerate overnight trays. Also, patients with tetracycline staining.
We also offer it to patients who don’t have 30-90 minutes free a day to wear their whitening trays.
Sensitivity
Also, for patients with tooth sensitivity, Philips says Nitewhite gel may be suitable because it is slow-release. However, in my personal experience, patients who have really sensitive teeth do better with Daywhite for a shorter period of time (about 30 minutes). The slow release can make them a little more sensitive. This is why it is important to tailor whitening to individual patients and evaluate it on a case-by-case basis.
All Zoom whitening gels contain amorphous calcium phosphate (ACP), which reduces tooth sensitivity. There is also the option to give them the added protection of ACP Relief Gel if they need it.
For chairside whitening procedures, I use the Philips Zoom White Speed lamp. This accelerates the hydrogen peroxide gel and therefore speeds up the process. The light-activated technology is proven to be safe and effective on teeth and gums. Thanks to the adjustable settings, you can control the intensity of the whitening.
I tend to always have it on a high setting and so far my patients have not experienced any sensitivity – in fact 90% of respondents experienced little to no sensitivity with the Philips Zoom White Speed.
Understanding the legislation
Patients must be dentally fit to undergo whitening, so prior to treatment they need a full assessment for any cavities, lesions and periodontal disease. If you have a patient with periodontitis and you are about to start a course of treatment, you need to stabilize their period before you go ahead and do the whitening.
It is also important to make sure patients know that whitening will not work on porcelain crowns or veneers, fillings or composites and therefore may need a restorative replacement afterwards to match the bleached teeth. You also want to allow time for the shade to settle before replacing these restorations.
Setting patient expectations is important to avoid problems later on. Identify stained areas on teeth where whitening may accelerate fluoride or hypercalcification. In my experience, white spots tend to lighten quite quickly, which makes them stand out a little more, so let patients know that once they’ve completed the at-home whitening treatment, these white spots go away.
Some teeth may not whiten based on anatomy and shades cannot be guaranteed. This is important for all your patients to know at the first session.
It is best practice to obtain signed informed consent for patients confirming that they understand the bleaching procedure they are about to undergo. You need to make sure that all these tips are included in the consent form.
Shade shooting tips
At the beginning of the whitening appointment, it is recommended that you use a shade guide to assess the level of tooth pretreatment before any dehydration begins. You want to make sure this is done using natural light where possible. .
Using a mirror, show the patient a selection of shades – including one shade lighter and one shade darker – decide and agree their initial shade together, before starting the treatment.
I personally tend to manage their expectations and emphasize that we cannot predict the final shade. Always document everything in your notes.
Patients who already have lighter shades of teeth will end up with results that are not as visually impressive and this is also something to watch out for. If they dispute the result, you can show them the starting point marked in their notes.
Internal and external staining
External staining can be removed by peeling and polishing. Internal pigmentation requires bleaching to improve the color, but there is no guarantee that it will work for everyone.
Teeth are usually made up of many colors and there are gradations from top to bottom of the tooth. They can become darker due to age, presence of secondary dentin, incorporation of extrinsic stains, gradual wear or abrasion of enamel, genetics, and use of antibiotics such as tetracycline.
A tetracycline stain is a difficult stain that can be removed or improved with the right treatment. However, it may take one to six months to achieve the desired improvement.
The gray spot is calcified dentin, which is common in elderly patients. The whitening process is slower and I would recommend Zoom Nitewhite to deal with that.
Yellow, brown, or orange stains are the easiest stains to bleach and often appear in younger patients.
Sensitivity management
ACP gel is available for purchase by patients to use on whitening trays to relieve sensitivity. ACP precipitates hydroxyapatite and fluorapatite, unclogging dentinal tubules, which protect against sensitivity and improve tooth appearance by restoring enamel luster to create a smoother, glossier appearance (Giniger et al, 2005).
Patients can even brush their teeth with the ACP gel or put it on their trays without the whitening gel and leave it for 30 minutes, which can help calm the teeth.
Capture impressions
When you perform chairside whitening and offer home whitening in combination, you ideally want to have the custom whitening trays ready to fit at the chairside whitening appointment, as this means the patient can start whitening at home the same evening.
In my office, I take impressions at the beginning of the appointment and my nurse prepares the whitening trays while the patient bleaches in the chair, which saves the patient needing an extra appointment.
You may not have the ability to make the trays at home, so you can schedule a short initial appointment to take shadows, photos and impressions, send them to the lab, and take the trays back so you can place them during a subsequent whitening session in the chair.
Review
I usually bring patients back for a review 10 days to two weeks after their whitening appointment. The assessment appointment is an opportunity to take more photos and assess the shade achieved. Ideally, you will have recorded the shade at the start, the shade reached at the end of chairside bleaching, and the shade achieved at the evaluation appointment.
Patients can then decide if they want to boost the whitening a little more, so you can give or sell them some extra gel at that appointment.
bibliographical references
Giniger M, Macdonald J, Ziemba S, Felix H (2005) The clinical performance of professionally administered whitening gel with added amorphous calcium phosphate. J Am Dent Assoc 136(3): 383-9
For more information, visit www.philips.co.uk.
