Tooth whitening 101 – part one
Dentistry Study Club hosted various webinars with Andy Wallace, Megan Fairhall and Affan Saghir on tooth whitening recently. Here is the first in a five part series covering everything you need to know about offering tooth whitening in your dental practice.
Lockdown has been an opportunity for the dental profession to catch up on their education.
Philips Oral Healthcare sponsored a number of webinars on tooth whitening. The Philips team were delighted to see how so many dentists, hygienists and therapists were enthusiastic to learn more about the subject.
Aerosol-free tooth whitening is an attractive practice builder, which can involve the whole dental team. Here are the questions and answers provided by Dr Affan Saghir, Dr Andrew Wallace and dental hygienist Megan Fairhall during their webinars.
What types of whitening do you work with?
Megan Fairhall: There are two types of whitening that I offer to my patients.
Firstly the Zoom! take-home whitening trays. These consist of around two weeks of whitening at home with either a day or night gel.
The other option is the Zoom! chairside treatment.
Both are Philips treatments and I cannot advocate these enough. Using a reputable brand backed up by clinical research gives me peace of mind when offering treatments to my patients. Philips is also a well known brand and often requested by my patients for their whitening treatments.
The Zoom! chairside treatment takes around an hour and a half and claims up to six shades whiter in that time. It uses a 6% hydrogen peroxide gel – this is the highest amount of hydrogen peroxide we can legally use in the UK.
With the Zoom! chairside whitening treatment, I also recommend patients have the take home trays in addition. And that they use them for two to five days after the Zoom! in chair procedure. As opposed to just using the trays for two weeks as a stand alone home treatment.
This is to ensure the best, long-lasting results and means the patient also can use the trays for future whitening top ups.
What is the difference between day and night gel?
Megan Fairhall: The Daywhite gel is a 6% hydrogen peroxide and the Nightwhite gel is either a 10% or 16% carbamide peroxide.
The Nitewhite gel is broken down into hydrogen peroxide and urea. Therefore it has a slower reaction time. Meaning patients can use it over a longer period of time, ie overnight.
Patients can also use the Nitewhite gel during the day over a period of four hours. The gel is the most active in its first four hours. Patients who suffer from sensitive teeth for example could use it this way.
The Daywhite gel is a 6% hydrogen peroxide. This is used for both the Zoom! in chair procedure and also in the take-home trays. It’s for those patients who would rather do the whitening during the day. They can use it for up to one hour during the day in the take home trays.
Do you use reservoirs for whitening?
Megan Fairhall: Studies have shown that reservoirs don’t necessarily make a difference to the whitening results. So I don’t personally use them.
However, other clinicians may wish to use them if they feel a patient would benefit from an ability to visually see the reservoirs and so they then know exactly where to place the whitening gel in the trays.
How much clinical time do you require for a bleaching treatment?
Megan Fairhall: Usually an hour and a half for the Zoom! in chair treatment.
I would recommend blocking out two hours initially if you are new to carrying out the procedure. However, after a few treatments and subsequent experience in setting up the patient you will soon pick up speed. The more you do it, the quicker you become.
For the take home trays, you need to factor in the following; firstly an examination for the patient with the dentist to ensure they are dentally fit and that a prescription is in place to carry out the whitening treatment.
I would then see the patient to take impressions for the take home trays and any hygiene treatment if necessary.
The patient would then return for the fit and demonstration of use once the trays are returned from the lab. I would initially recommend the patient uses the take home trays for two weeks and then returns to see me for a review.
What is the standard protocol when carrying out whitening treatment?
Megan Fairhall: After patients have their initial review after two weeks or once they are happy with their whitening results. I would then typically ask them to come back six months later as part of their oral health maintenance. This is for an examination with the dentist and hygiene appointment with myself.
At that point I also review their shade and discuss if a whitening top up is required. Top up treatments are often based on the patient’s preference and their lifestyle habits.
I would also advise them to continue with regular hygiene and airflow appointments to help maintain the colour of their teeth.
The Philips whitening top up kits come in a smaller kit containing three syringes. We can order in the 6% hydrogen peroxide and both the 10% and 16% carbamide peroxide.
How long does a whitening syringe last?
Megan Fairhall:With the Philips take-home gel, there are measurements marked on the side of the syringe. So patients can monitor how much they are using.
Each tube should last around three days. Although many patients find it lasts a day or two more. Especially if they are not whitening their posterior teeth.
What is the difference between percentages?
Megan Fairhall: We are all different. I find people can respond differently to the different percentages. So tailoring the treatment to each individual case is extremely important to get the best long lasting results.
The 16% Nitewhite I find gets quicker results as it is a higher percentage. However, this may result in a higher level of sensitivity for patients. Potentially impacting on the patients compliance, and in turn their whitening results.
The 10% may result in a more comfortable experience. It’s likely to cause less sensitivity and therefore, patients are more likely to comply and get better results. Although as the 10% is a lower percentage is may take a bit longer to get the desired results.
It is always important to offer a tailored treatment to each patient. Not one size fits all when it comes to whitening treatments. This is something I cover in great detail during my whitening training courses to ensure dental hygienists and therapists are getting the best consistent results for their patients.
How long do you need to wait between whitening and composite bonding?
Affan Saghir: After whitening, it takes between 14 days and three weeks for the oxygen-free radical particles to dissipate out of the tooth’s surface. As a result, two to three weeks after whitening you can fit the composites.
If a patient is having Invisalign treatment and has 10 aligners, after tray number five you should start whitening for three weeks.
After this, stop whitening until the end of treatment. This gives you enough time to start the composite workflow once the alignment is complete.
Can you whiten teeth with attachments on?
Affan Saghir: You can whiten with attachments on, using aligners. The whitening gel diffuses into the tooth, whitening the enamel underneath the attachment.
Once the patient’s alignment journey is complete, you simply take the attachment off for uniformly whiter teeth.
What is the timing of whitening within clear aligner therapy? Is it at the beginning, middle or towards the end?
Andrew Wallace: I will try to plan the whitening of the patient’s teeth when they are in the last few weeks of alignment. After the patient completes the most significant tooth movements.
This keeps the motivation high and the trays will still fit really well as the movements are smaller.
Can patients continue with whitening with retainers?
Andrew Wallace: All my aligner patients get a new removable retainer after the fitting of the fixed retainer and any edge bonding.
At the same time I make this, I make a new bleaching tray for ongoing maintenance.
What other options do we have for trays?
Megan Fairhall: Philips partnered with IAS Lab to offer practices the highest quality bleaching trays produced to your exact specifications.
You send the impressions off. You request the whitening gel percentage you wish to have (6% hydrogen peroxide, 10% carbamide peroxide or 16% carbamide peroxide) and they send back the customised trays. This is so easy and means that you don’t need to have any stocks in practice.
IAS makes the most incredible trays with a very good seal that makes all the difference. You do not want saliva to get in nor gel to get out.
Good trays mean good results mean happy patients!
What is more effective, at-home or chairside whitening?
Affan Saghir: I firmly believe that at-home teeth whitening works better.
I haven’t read any systematic review article to support in-surgery whitening. All the evidence points towards a lower concentration of solution over a longer period of time at home to be the most effective.
What type of tray should you use?
Affan Saghir: The most important thing is that the tray is accurate, and tight fitting, so a good impression is key.
I like trays without reservoirs best, with scalloped edges to ensure there is no leaking. This will ensure the gel absorbs effectively into the tooth.
If a patient hasn’t achieved a satisfactory result, what can you do? Would you recommend a longer period of treatment?
Andrew Wallace: I try to identify the more difficult cases and modify the patient expectations.
If they need another tube or two of gel that’s no problem. But using the techniques I described in the webinar I rarely have anyone who is not satisfied.