In a world of social media and smartphones, we are only ever one click away from a photo being snapped and shared with the world. It is making people more aware than ever of how their teeth – and their smiles – look…
With more people opting for aesthetic dental procedures, treatments are becoming more advanced as well as more affordable. Nowadays more people are commencing tooth whitening because of its affordability, safety and ease. It will improve the patient’s self-confidence, encouraging them to smile, boost their careers, and make them look younger.
Tooth whitening treatments have grown in numbers as consumer demand has increased. Today there are numerous options on the market, from those carried out at home to those administered in dental surgeries.
Treatment options fall into four categories:
• Air polishing
Peroxide whitening Peroxide whitening involves bleaching the teeth, and can be broken down into three distinct categories:
• Strips, pens, pre-made trays
• Professional home whitening
• Professional ‘power’ bleaching in-office: all soft tissues are isolated, and chemically activated gel is applied to the tooth’s surface. In some cases a light is then put into position and directed at the gel to ‘enhance’ whitening.
THE OPTIONS FOR TOOTH WHITENING
- Whitening toothpaste
Easily accessible over the counter, whitening toothpastes contain more abrasives or additives which work to break down and remove surface stains and revive the tooth’s natural colour.
- Scale and polish
A regular scale and polish is often enough to keep a natural smile clean and bright, while maintaining the integrity of the tooth surface. Prophylaxis treatments such as AirFlow use a silicone coated powder which remove stains effectively and quickly without impacting on the surface of the tooth.
- Smile strips and preloaded trays
This delivery of Hydrogen Peroxide is a professional alternative to less predictable over the counter products. They don’t require impressions and can be used immediately.
- Custom tray whitening – the gold standard
Carbamide Peroxide or Hydrogen Peroxide gel in a custom fabricated tray is the traditional tried and tested way to lighten the internal pigments of teeth. This approach improves the appearance of teeth without altering any tooth structure.
Using silicone carbide combined with hydrochloric acid, fluorosis staining can be gently removed using chemical abrasion in less than 0.2mm enamel depth.
- In-surgery whitening
Hydrogen Peroxide formulations are generally used for this type of procedure. Due to their quick penetration, the results are more immediate, although this often requires an aftercare home treatment to ensure that the change in shade is stable.
- RCT and walking bleach
This is a very effective way to lighten non-vital teeth that have been discoloured by trauma or over time. Using the ‘walking bleach’ technique, the remaining tooth structure can be lightened to the required shade in a very controlled way over several weeks.
- Composite restorations
Composite is an effective restorative material for altering shade, shape and surface texture of teeth. It wears like natural tooth structure, and occasionally requires some maintenance to keep its appearance looking vital with high shine.
Porcelain is renowned for its high quality aesthetics, function and extensive research. Lab communication, bonding and cementation are key elements in getting the best results. Full smile design cases can attract higher costs, but can have a significant impact on patients’ lives.
Crowns require more severe removal of tooth structure, and this is often only recommended when there isn’t a suitable alternative treatment.
When it comes to whitening agents, the two key choices are Hydrogen Peroxide (HP) or Carbamide Peroxide (CP). These come in different strengths.
- 6% Hydrogen Peroxide (equivalent to approx. 18% Carbamide Peroxide) – the strongest EU accepted whitening gel can be used at home by the patient in a custom fabricated tray for 30-90 minutes at a time.
- 16% Carbamide Peroxide – this gives very similar results as the 6%HP. However, due to the make up of Carbamide Peroxide, it breaks down slower meaning the ideal time to wear this treatment is around 2-4 hours.
- 10% Carbamide Peroxide – this is the original percentage of gel used in NGVB (Nightguard vital bleaching – also known as ‘tray bleaching’ or ‘at-home bleaching’) This has been proven to be very effective when worn in a custom tray overnight, or for up to 8 hours at a time.
- 5% Carbamide Peroxide – this is ideal for patients who suffer from sensitive teeth, however only one company currently has a product this strength. It has a patented chemistry which makes it as effective as a 10%CP due to an active alkalinity boost.
Most patients that have a shading of A&B (according to the VITA shade standard) will be very responsive to whitening and will often reach very light shades in one to two weeks. Patients that have dark staining – a VITA shade of C&D – may require a longer treatment plan due to the nature of the pigments in the dentine.
TIP: The length of the treatment will vary, depending on the specific case, but will not usually exceed three weeks. (The first week to treat the upper arch, the second week to treat the lower arch, and the third week in which both arches are treated to reinforce and stabilise the final result).
Some people do not carry pigments in the body, and up to 5% of the population may not respond to bleaching at all. This can be discussed with your patients in order to manage expectations prior to treatment.
THE IMPORTANCE OF TRAY DESIGN
The design of the tray is just as important as the gel itself. The tray needs to fit snugly around the patient’s teeth. If it doesn’t, the gel can escape or become diluted. If the tray is not finished correctly, it can also irritate the gums and be very uncomfortable. It is generally recognised that the most efficient and effective methods of applying whitening products to natural teeth is via a custom made whitening tray. To be as effective as possible, this tray must be professionally made.
Customised trays can accommodate virtually all patients’ requirements. This can include a ‘full mouth’ tray or a modified tray, which can be designed to whiten selected teeth only.
- Making an impression
An accurate impression is important. A whitening tray can only be effective when certain criteria are met. Ideally, impressions should only be taken in a rigid impression tray. This prevents any risk of distortion, which can lead to a poor fit. When the laboratory receives an impression, it can accurately cast models in a highly permeable model stone.
The dentist chooses to go with or without reservoirs, and the tray must be scalloped correctly followed by flaming and smoothing of the trimmed margins. This will help to ensure that an accurate sealing at the gingival margins is achieved.
The laboratory recommends a finished tray thickness of 1mm. This allows sufficient flexibility of the tray when the patient is inserting and removing it from their mouth. A correctly made tray will help the patient to achieve optimum results from the whitening gel, without any of the problems that can be experienced with ‘one size fits all’ home whitening products.
- 3D Imaging
Digital Impressions through 3D imaging are becoming more widely used, and this is particularly effective in ensuring accurate tray design. Most good laboratories will have this service available.
As with the advent of any new technology, it’s important for dental professionals to consider new alternatives. In the case of 3D dental imaging, the advantages are clear, offering practitioners and patients alike a better clinical experience.
A 3D dental image can also be used multiple times, offering a fast, accurate approach that is consistent and reliable.
CHOOSING THE RIGHT GELS AND SAFETY
• pH level – Peroxide is most efficient and active at a neutral pH of 7.0 or above. Some companies struggle to stabilise the product and, therefore, reduce the pH level to compensate this. This makes it more acidic and increases the chance of sensitivity and possible damage to the enamel. Make sure you choose a gel with a near neutral pH that has as an increased alkalinity once applied.
• Tray design – Tray design is important in any bleaching procedure. There must be a good seal around the gingival margin, regardless of reservoirs on the labial surface. The gel will not run out of the trays if it is the right viscosity.
• Water content – It is important for gels to be water based, as peroxide dehydrates the teeth. Look for a gel with a high water content of approximately 20% that still retains optimum viscosity.
• Desensitiser – Some gels contain desensitisers such as Potassium Nitrate and Fluoride, which are very effective at reducing sensitivity during the treatment. It is advisable to bear this in mind when making a decision.
• Flavour – Many products contain glycerine to prolong the shelf life of their products. This can negatively impact the taste of the gel and can be hard to mask. Choose something that has a fresh flavour and will make the treatment more pleasant for your patients.
Reference: Modified StyleItaliano Guide