Dental hygienist Steven Scannell discusses his experience of tooth whitening and offers his top tips.
When you look at global tooth whitening trends, there is no doubt that 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.
With a view to encouraging more dental professionals to start the business of whitening, I was recently asked to share my tooth whitening tips. The fear of the unknown is very natural. But I hope I was able to reassure my peers that whitening can make a significant addition to the 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 if patients should undergo whitening, and if so, which treatment will work best for them.
I wouldn’t advise pregnant and breastfeeding women to have their teeth whitened. The same is true for people who partake in excessive alcohol and/or tobacco consumption, immunocompromised individuals, people with allergies to any of the ingredients within the whitening products and those under the age of 18.
Smokers can undergo whitening, but should be advised on cutting down or ceasing to make the whitening results worthwhile.
The right whitening system
In our practice, we use Philips’ Zoom Daywhite and Nitewhite take-home products. For those patients who want fast results, we offer a Zoom in-chair procedure so we can offer a range of options to treat our patients’ varied lifestyles.
The hydrogen peroxide (H2O2) gel used in Daywhite penetrates through the enamel and while absorbed, the peroxide decomposes into water and oxygen molecules. These oxygen molecules break up the double carbon bonds of the stain molecules chromophores, making those molecules appear colourless.
I tend to use Daywhite for patients who have a lighter starting shade. Also, those who would struggle wearing trays at night and who want quick results. Daywhite treatment takes about 30 to 90 minutes a day for two weeks.
Zoom Nitewhite gel comprises carbamide peroxide, which breaks down into hydrogen peroxide and urea. As it has a slower release rate, it can be used when longer contact time with the teeth is possible.
Nitewhite is available in two strengths: 10% and 16% carbamide peroxide. The recommendation is to use the 10% for two to four hours and the 16% for four to six hours. This treatment option tends to be for patients with darker shaded teeth, who can tolerate the overnight trays. Also, patients with tetracycline staining.
We also offer it to patients who don’t have 30-90 minutes free in the day to wear their whitening trays.
Sensitivity
Also, for patients with tooth sensitivity, Philips says Nitewhite gel may be suitable because it is a slow release. However, from my personal experience, patients who really have sensitive teeth get on better with the Daywhite for a shorter time (around 30 minutes). The slow release may make them become a little bit more sensitive. This is why it is important to tailor the whitening to individual patients and assess on a case by case.
All the Zoom whitening gels contain amorphous calcium phosphate (ACP), which limits tooth sensitivity. There is also the option to offer them the additional protection of ACP Relief Gel if they need it.
For my in-chair 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 safe and effective on the teeth and gums. Thanks to the adjustable settings, you can control the intensity of the whitening.
I tend to always have it on the high setting and, so far, my patients haven’t experienced any sensitivity – in fact, 90% of people surveyed experienced little to no sensitivity with the Philips Zoom White Speed.
Understanding the legislation
Patients need to be dentally fit to undergo whitening, so before treatment they need a full assessment for any caries, lesions and periodontal disease. If you have a patient with periodontitis and about to start a course of treatment, you need to stabilise their perio before you go ahead and undertake the whitening.
It is also important to make sure patients are aware that whitening won’t work on porcelain crowns or veneers, filling materials or composites and as a result they may require restorative replacement afterwards to match the whitened teeth. You also want to allow time for the shade to settle down before you replace those restorations.
Setting patients’ expectations is important to avoid issues at a later stage. Identify patchy areas on the teeth where whitening may accelerate fluorosis or hyper calcification. From my experience, white spots tend to brighten up quite quickly which make them stand out a little bit more, so make patients aware of that once they finish the home whitening treatment these white spots settle back down.
Some teeth may not whiten based on anatomy, and it is not possible to guarantee shades. This is important to let all your patients know that at the first consultation.
It is best practice to gain signed consent for patients confirming they understand the whitening procedure they are about to undergo. You need to ensure all this advice is included on the consent form.
Shade taking tips
At the very start of the whitening appointment, it is recommended that you use a shade guide to assess the level of the teeth pre-treatment before any dehydration sets in. You want to make sure this takes place using natural light where possible to do so.
Using a mirror, show the patient a selection of shades – including one shade lighter and one shade darker – decide and agree their starting shade together, before you start the treatment.
I personally tend to manage their expectations and emphasise that we cannot predict the final shade. Always document everything in your notes.
Patients who have already have lighter shades of teeth will end up with results that are not as visually impactful, and that is also something to be mindful of. If they question the outcome, you can show them the start point that has been annotated in their notes.
Intrinsic and extrinsic staining
Extrinsic staining can be removed by scaling and polishing. Intrinsic staining requires whitening to improve the colour, but there is no guarantee it will work for everyone.
Teeth are typically made up of many colours and there are gradations from top to bottom of the tooth. They can become darker because of age, the presence of a secondary dentine, the incorporation of extrinsic stains, gradual attrition or abrasion of the enamel, genetics, and use of antibiotics such as tetracycline.
Tetracycline stain is a challenging stain that can be removed or improved with the correct treatment. However, it may take as long as one to six months to achieve the desired improvement.
Grey stain is calcified dentine, which is common in older patients. The whitening procedure is slower and I would recommend Zoom Nitewhite to tackle this.
Yellow, brown or orange stains are the easiest stains to whiten and are often seen in younger patients.
Sensitivity management
The ACP gel is available for patients to purchase to use in their whitening trays to relieve sensitivity. The ACP precipitates hydroxyapitite and fluorapatite, occluding the dentin tubules which protects against sensitivity, and also improves the appearance of teeth by restoring enamel lustre to create a smoother, glossier appearance (Giniger et al, 2005).
Patients can even brush their teeth with the ACP gel or put in their trays without the whitening gel and leave it in for 30 minutes, and that can help to settle down the teeth.
Impression taking
When you carry out in-chair whitening and offer home whitening in combination, you ideally want to have the custom whitening trays ready to fit at the in-chair whitening appointment, as this means the patient can start the home whitening the same night.
At my practice, I take the impressions at the start of the appointment and my nurse makes the whitening trays while the patient is having the in-chair whitening, which saves the patient needing an additional appointment.
You may not have the facilities to make the trays in-house, in which case you can schedule a short initial appointment for shade-taking, photos and impressions, send them off to the lab and get the trays back so you can fit them during a subsequent in-chair whitening session.
Review
I typically get patients back for review 10 days to two weeks after the whitening appointment. The review appointment is an opportunity to take more photos and assess the shade that has been achieved. Ideally, you will have logged the shade at the start, the shade reached at the end of the in-chair whitening and the attainment shade reached by the review appointment.
Patients can then decide if they would like to boost the whitening a little bit further, at which point you can give them or sell them some extra gel at this appointment.
References
Giniger M, Macdonald J, Ziemba S, Felix H (2005) The clinical performance of professionally dispensed bleaching gel with added amorphous calcium phosphate. J Am Dent Assoc 136(3): 383-9
Fore more information, visit www.philips.co.uk.
