Pt perceptions of the “Hollywood Smile” has no doubt increased interest in cosmetic rx
Link to sites who are providing whitening illegally and esp. interesting where they offer to carry out an examination..
I.E. An example of clear clinical need would be when alternative treatments for a defined clinical problem, such as the provision of labial veneers or crowns, would be more destructive to tooth tissue than bleaching. This would not, therefore, include cases where a patient merely wishes to have their teeth made slightly lighter. The over-riding principle, therefore, should be that the patient’s best interests are being served through the provision of tooth bleaching.
COLOUR Teeth made of many colours, with natural gradation from the darker cervical to the lighter incisal third Variation affected by thickness of enamel and dentine, and reflectance of different colours Blue, green and pink tints in enamel, yellow through to brown shades of dentine beneath Canine teeth darker than lateral incisors Teeth become darker with age (secondary/tertiary dentine, tooth wear/dentine exposure)
COLOURTooth colour affected by: individual interpretation time of day patient positioning/ angle tooth is viewed at hydration of tooth (always take shade at start of appointment) skin tone (make-up) surrounding conditions (e.g. lighting in clinic)
CLASSIFICATION OF TOOTHDISCOLOURATION Extrinsic discolouration Intrinsic discolouration
AETIOLOGY OF DISCOLOURATIONExtrinsic Discolouration: Stains (chromogens) that lies on/attach to the tooth surface or in the acquired pellicle, or The incorporation of extrinsic stain within the tooth substance following dental development. It occurs in enamel defects and in the porous surface of exposed dentine (‘stain internalisation’).
AETIOLOGY OF DISCOLOURATIONExtrinsic Discolouration:E.g.•Plaque, chromogenenic •Smoking / chewingbacteria tobacco•Mouthwashes •Beverages (tea, coffee,(chlorhexidine) red wine, cola) •Foods (curry, cooking oils and fried foods, foods with colorings, berries, beetroot) • Antibiotics (erythromycin, amoxicillin-clavulanic acid) • Iron supplements
AETIOLOGY OF DISCOLOURATIONIntrinsic Discolouration: Intrinsic discolouration occurs following a changeto the structural composition or thickness of thedental hard tissues.
AETIOLOGY OF DISCOLOURATIONIntrinsic Discolouration:Pre-eruptive: Post-eruptive:Disease: Trauma (e.g. pulpal •Haematological diseases haemorrhagic products) •Liver diseases Primary and secondary •Diseases of enamel and caries dentine (e.g. Amelogenesis/ Tooth wear Dentinogenesis imperfecta) Dental restorative materialsMedication: •Tetracycline, other antibiotics AgeingFluorosis stains (excess F) ChemicalsEnamel hypoplasia (trauma Antibioticsor infection) Minocycline (used to treat acne)
Types of Discoloration Colour ProducedExtrinsic (Direct stains)Tea, coffee and other foods Brown to blackCigarettes/cigars Yellow/brown to blackPlaque/poor oral hygiene Yellow/brownExtrinsic (Indirect stains)Polyvalent metal salts and cationic antiseptics Black and browne.g. ChlorhexidineIntrinsic(Metabolic causes)e.g. Congenital erythropoietic porphyria Purple/brown(Inherited causes)e.g. Amelogenesis Imperfecta Brown or blacke.g. Dentinogenesis Imperfecta Blue-brown (opalescent)(Iatrogenic causes)Tetracycline Banding appearance: classically yellow, brown, blue, black or greyMinocycline GreyFluorosis White, yellow, grey or black(Traumatic causes) BrownEnamel hypoplasia Grey blackPulpal haemorrhage products Pink spotRoot resorption(Ageing causes) YellowInternalizedCaries Orange to brownRestorations Brown, grey, black
MANAGEMENT OF DISCOLOUREDTEETHTreatment options: 1.No treatment 2.Removal of surface stain 3.Bleaching techniques 4.Operative techniques to mask underlying discolouration Veneers Crowns
Treatment option Indications Advantages DisadvantagesNo treatment Patient with poor oral Non invasive, no cost Will not address hygiene/ caries/ PA patients aesthetic pathology, large ant concerns restorations/crownsRemoval of surface Non/minimally invasive May not improvestain aesthetics significantly,-Scale and polish may require further Rx -Extrinsic staining-Microabrasion Microabrasion- soft -Fluorosis, white spot tissue irritation/ demineralisation, excessive tooth prep enamel hypoplasia (technique sensitive)Bleaching Non/minimally invasive Cost, limitation on-Home bleaching, -See later slides shade improvement (aWalking bleach few shade lighter only), may fail/ need repeating, compliance (home bleaching)Restorative treatment Severely discoloured May achieve a more Destructive, irreversible-Veneers, crowns teeth, e.g. tetracycline aesthetic result (tooth tissue removal), staining (may bleach changes natural shape 1st) of teeth, cost, Unaesthetic tooth maintenance, oral morphology (e.g. AI/DI) hygiene compliance (interdental cleaning) Heavily restored teeth
GENERAL INDICATIONS Generalised staining Ageing Extrinsic stain - Smoking and dietary stains (tea/coffee etc) Fluorosis Tetracycline staining (? in combination with restorative techniques) Traumatic pulpal changes White spots Brown spots (not as good response)
CONTRAINDICATIONSPatients with high/unrealistic expectationsDecay and active peri-apical pathology (must beresolved first)Pregnancy/BreastfeedingSensitivity/cracks/exposed dentineExisting crowns / large restorations (anteriorly)Elderly patients with visible recession and yellowroots (roots don’t bleach as readily as crowns)If patients cannot afford changing existingrestorations post-bleaching
Effects onSoft tissuesCervical resorptionPulpHardness of teethTooth coloured restorationsAdhesive bond strength -changes composition of enamel and dentine, therefore defer definitive adhesive restorations until 2 weeks (at least 10 days) after bleaching completed
BLEACHINGDefinition “any treatment procedureor method a dentalprofessional might prescribeto whiten the color andbrighten your teeth”10-15% carbamide peroxideused as a oral disinfectantsince late 1960s – LONGCLINICAL HISTORY
BLEACHING TECHNIQUES Vital bleaching : • Home use of 10 % (15%, 20% ALSO) carbamide peroxide in a dental tray • “In office bleaching” (~30% carbamide peroxide) carried out in single visit (photo initiation) plus additional home use of carbamide peroxide 10% to “top up” Non-vital bleaching : • (A.k.a Walking bleaching) • The ‘Inside/Outside’ method using 10 % carbamide peroxide
MATERIALS1. Hydrogen peroxide (HP): H2O22. Carbamide peroxide: CH6N2O3 much more stable than hydrogen peroxide, hence it’s preferred use • Urea stabilises and buffers HP – shelf life! • A 10% Carbamide peroxide solution contains 3% HP, 7% Urea1. Tetrahydrate sodium perborate: NaBO3 (Borax) mixed with water- decomposes to HP.
MATERIALS Why 10% CP most widely used? • 10% is the only bleaching concentration approved by the FDI • Majority of clinical data on 10%, if a lawsuit ensued – could be criticized for using something less well “tested” • Higher concentrations= increased sensitivity and harmful effects
MODE OF ACTION Thought to be due to the ingress of oxidisers and oxygenating molecules through enamel micropores. Break/cleave pigment bonds and allow molecules to diffuse through the tooth &/or become smaller and absorb less light and hence appear lighter
MODE OF ACTION 2 When bleach is applied to the tooth it passes from the incisal edge to the apex of the tooth through the enamel, dentin & pulp chamber within 5- 15 minutes. Hydrogen Peroxide breaks down very rapidly to water, an oxygen ion and oxygen free O- radicals. The 3 or 4 most H2O active free radical species are H2o2 OH- OH- 95%, OOH- 2.3% & O- O2 2.3%. OOH-
MODE OF ACTION 3 The oxygen molecules then attach to the double carbon bonds (colour stain molecules) and break them down into OH- DCB single carbon bonds, thus O- disfiguring their internal colors. DCB OOH- The Single carbon bonds reflect light and therefore BREAK DOWN THE STAIN MOLECULES make teeth appear brighter and whiter. The changed molecules are now translucent. SCB SCB The molecules may also now diffuse through the pores more readily because of their reduced size
LEGAL SITUATION The situation at present is that it is illegal in the UK to supply a product for the purpose of tooth whitening, if that product contains or releases more than 0.1% Hydrogen Peroxide. Companies are able to supply as a “chemical” only i.e. without instructions for use in bleaching 10% CARBAMIDE PEROXIDE RELEASES ~3% HYDROGEN PEROXIDESO ESSENTIALLY IT’S ILLEGAL PRACTICE...
LEGAL SITUATIONHoweverChief Dental Officer Statement 2000:“The Department of Health would notseek to interfere with a dentist’stherapeutic decision to utilize ableaching technique where a dentistconsiders this to be in the best interestsof the patient’s overall oral health care”
LEGAL SITUATIONTooth whitening update (September 2011)- Dental Protection:• New European Directive allowing dentists to legally supply products for tooth whitening, which release or contain up to 6% hydrogen peroxide , provided that the patient has been examined by a dentist and the first treatment has been performed by the dentist or under his or her direct supervision.• Once in place (due for publication in October 2011), the UK Government is obliged to amend the Regulations to reflect this within 12 months.• 6% HP limit will allow dentists to use 18% CP
GENERAL DENTAL COUNCILGDC The GDC believes that it is illegal for non-dental professionals to be offering tooth whitening treatment. We advise any member of the public wanting tooth whitening to speak to their dentist. In our view tooth whitening amounts to the practice of dentistry. The carrying out of dentistry by non-registrants is a criminal offence. We are committed to protecting the public by investigating and prosecuting people who are not registered with us and who perform, or provide clinical advice about, tooth whiteningBEWAREhttp://www.smilestudiowirral.co.uk/procedure.htmlhttp://www.circlesmk.co.uk/pages/teeth.html
ETHICAL CONSIDERATIONS The end point is fixed for all teeth and this must be explained fully to the patient. The Professional should explain the various treatment options, incuding bleaching alternatives such as toothpastes, OTC, at home tray and in-office so that an informed decision can be made. You must not lead a patient to believe that in- office bleaching will yield better results than home bleaching.
LIVERPOOL UNIVERSITY DENTALHOSPITALAt the LUDH, our bleaching protocol states: “tooth bleaching should only be done if there is a real, clearly-defined clinical need to provide this form of treatment and not merely for the cosmetic aspirations of a patient”.
Bleaching: Part IIWalking Bleach/ Non-Vital Bleaching
NON-VITAL BLEACHING Spasser (1961) - sodium perborate sealed within canal (walking bleach) Nutting and Poe (1963, 1967) – combination walking bleach (perborate and HP) Now carbamide peroxide 10% used widely Known as walking bleaching Indications: To whiten endodontically treated, discolored teeth.
NON-VITAL BLEACHING- RISK:• External (cervical) resorption, especially when used with thermocatalytic activation (heated instrument within pulp chamber)• Heithersay found incidence increased when associated with trauma (3.9-9.7%) and orthodontic treatment (24%)
CLINICAL RELEVANCE: Pre-operative radiograph • ensure no pathology (external resorption) prior to commencing procedure • medico-legal Warn patient if previous orthodontic treatment or trauma- higher risk Sealing GP with a 2mm RMGIC (minimum 2mm to prevent ingress of bleach into pulp chamber
WARNINGS Warn patient: • May not improve shade • May reverse, and patient may need to repeat procedure in future at own cost • May require other treatment: veneer/crown • Tooth is hollow whilst carrying out bleaching and patient must be careful, do not bit into hard foods, tooth may fracture! • Cervical resorption? Previous trauma/ortho • If temp filling lost must see dentist urgently (walking bleach)
NON-VITAL BLEACHING1. History taking & examination2. Examine the radiograph to establish adequate RCF3. Take shade and photograph4. Rubber dam isolation- single tooth5. Remove all filling material and gutta percha 2-3mm apical to CEJ (Williams/PCP 2 probe used).6. All restorative material must be removed to allow bleaching agent to contact the internal tooth structure.7. Mix RMGIC and place 2mm thickness to assure a seal. Light cure for 20s.8. Express Carbamide Peroxide into the cavity (use a small tip, e.g. the tips used for acid etch).
NON-VITAL BLEACHING9. Place tiny cotton pellet into gel. Leave 1.0 to 1.5mm of space to accommodate the provisional restoration.10. Place a GIC provisional restorative material to seal the access opening, check occlusion.11. Repeat the procedure every 3 to 7 days until the desired color change is achieved.12. Remove provisional restorative material and bleaching material to level of GI sealing material. Rinse and clean access opening. Place a temp restoration.13. A definitive resin composite restoration of a light colour should not be placed before 14 days after the bleaching process.
“INSIDE-OUTSIDE” BLEACHINGEssentially same technique as Non vital bleaching1. Pre-op radiograph (assess endo)2. Re-open access cavity3. Ensure chamber free of GP4. Seal off the root filling with resin-modified GIC5. Place the 10% gel (may be higher) into a single tooth tray with labial and lingual reservoirs.6. Insert tray into the mouth. Remove excess as necessary. This should be kept in position for at least 2 to 3 hours and preferably overnight.7. Clean the access cavities out with a toothbrush or interproximal brush.
“INSIDE-OUTSIDE” BLEACHING8. No limit to how many times the material can be changed and changing the material every 2 to 3 hours will probably speed up the process.9. The access cavity should ideally left open for no longer than necessary (suggested 3 days?)10. The chamber should be cleaned out thoroughly and temporised.11. A definitive resin composite restoration of a light colour should not be placed until 14 days after the bleaching process.
LUDH- PROTOCOL 1- Home Bleaching(aka Night Guard Vital Bleaching) Make a diagnosis of the cause(s) of discolouration and record this in the notes. Treatment plan: Discuss the various alternative treatment options to bleaching teeth, e.g. no treatment, veneers, crowns. Check that the patient is not allergic to peroxide or plastic. Identify the teeth for bleaching **check their periapical status on radiograph.
PROTOCOL 2• Record the shade of the discoloured teeth and write that in the notes.• Photograph if possible (with shade tab)• Obtain patient consent • Warn restorations will not change colour*• Take alginate impressions for tray- lab prescription*• Fit bleaching trays, ensure good fit and comfortable• Advise patient on procedure- demo use, give leaflets
PATIENT INFORMATIONUsing the 10% CP(Home Bleaching )1. Brush teeth and floss as normal before each use.2. Advise the patient to remove the tip from the syringe containing the 10% carbamide gel and to extrude a little (~1mm) of the gel into the deeper and front parts of the tray. (No more than ½ a syringe). Place gel in the tray on the cheek and the tongue side of the back teeth.3. Seat the tray over the teeth and press down firmly.4. A finger, a tissue, or a soft toothbrush should be used to remove excess gel that will flow beyond the edge of the tray.
PATIENT INFORMATION5. Rinse gently and do not swallow. The tray is usually worn whilst sleeping or a minimum of 2 hours.6. In the morning, remove the tray and brush the residual gel from the teeth. Rinse out the tray and brush it. Store it in a safe container. The patient should not eat, drink or smoke while bleaching trays in mouth. 10% CP should not be exposed to heat (decomposes), sunlight or extreme cold. Store in a fridge and keep away from reach of children.
PATIENT INFO 2• Advise the patient that it will probably take about 2-6 weeks to achieve satisfactory result • Nicotine stain 1-3 months • Tetracycline stain 2-6 months, sometimes 12• Further restorations may be required
POST WHITENING INSTRUCTIONS The Next 24 – 48 hours are important in enhancing & maximizing whitening results. Avoid substances which may stain teeth Such as: Red wine, coca cola, coffee, tea Sensitivity: Teeth can be sensitive for 24-48 hours (esp after in office bleaching). It can range from a dull ache in the teeth to sharp pains various teeth. Take Panadol or Nurofen as required.
SENSITIVITY Cause: •Passage of hydrogen peroxide through enamel and dentine to the pulp •Manipulation of teeth55% to 75% of patients experience sensitivity
SENSITIVITYAt risk patients: Large pulp chambers Exposed root surfaces Abfraction, attrition, erosion, abrasion lesions Over wearing of trays Improper fit of trays High concentrations of bleaching agent No long-term effects in the literature
TREATMENT OF SENSITIVITY•Decrease wearing time/concentration•Desensitizing toothpaste –Potassium nitrate • works on the nerve of the tooth •10 - 30 mins in a tray –Neutral Sodium Fluoride •occludes the dentinal tubules ( 4-6 weeks)•Relief gel, Tooth mousse –Amorphous Calcium Phosphate
MAKING THE TRAY• Take alginate impressions of arch(es) to be bleached• Technician to cast up and block-out the labial aspects of the teeth to be bleached if using reservoirs- recommended (lab technicians add flowable composite onto labial aspects of teeth)• Make a thin vacuum-formed soft tray from a thermoplastic material• Check this carefully on the model to ensure there are no sharp areas of the tray that might irritate the gingival margins.
LABORATORY PRESCRIPTION:Please:1. Pour study models in dental stone2. Place composite resin on labial surfaces on e.g. UR5-UL5, LR5-LL5 (+/- palatal surfaces), kept short of gingival margins3. Make upper and lower full arch, 1mm thickness, soft pull down bleaching trays which are well adapted and trim to the level of the gingival margins
REFERENCESDENTAL PROTECTION POSITION STATEMENT ON WHITENINGDr Van Haywood and Dr Harald Heymann published the original technique, called Nightguard Vital Bleaching, in an article in 1989http://www.dentalprotection.org/United_Kingdom/News_And_Information/P osition_Statements/20061014_ps_whitening.aspxSchool of Dental Sciences - Liverpool University Dental HospitalProtocols for Tooth Bleaching/Whitening (AJP)Suliman 2004 - Dental Update papers (links on vital)
FURTHER READING1. Greenwall, Linda. Bleaching techniques in restorative dentistry : an illustrated guide2. Haywood, Van B. TitleTooth whitening : indications and outcomes of nightguard vital bleaching / Van B. Haywood; Quintessence Publishing, 2007.3. Van Haywood’s article: Frequently Asked Questions About Bleaching; Compendium / April 20034. GOLDSTEIN, Ronald E Complete dental bleaching; 1995; Quintessence5. Sulieman M. An Overview of Bleaching Techniques: 1. History, Chemsitry, Safety and Legal Aspects. Dent Update 2004; 31:608- 6166. Sulieman M. An Overview of Bleaching Techniques: 2. Night Guard Vital Bleaching and Non-Vital Bleaching. Dent Update 2005; 32: 39-46
LUDH- PROTOCOL 1 Make a diagnosis of the cause(s) of discolouration and record this in the notes. Discuss the various alternative options to bleaching teeth, for instance, veneers, crowns and post crowns. Check that the patient is not allergic to peroxide or plastic. Identify the teeth for bleaching **check their periapical status on radiograph.
PROTOCOL 2• Record the shade of the discoloured teeth and write that in the notes.• Photograph if possible (with shade tab)• Record that in the notes and obtain patient consent • Warn restorations will not change colour*• Take alginate impressions for tray- lab prescription*• Fit bleaching trays, ensure good fit and comfortable• Advise patient on procedure- give leaflets
PROTOCOL 3• Check for the presence of composites, veneers, crowns at adjacent and opposite teeth and warn patients that these will not change colour with bleaching and may need to be redone if bleaching is undertaken as the colour mismatch may become much more apparent following bleaching.• If possible draw a diagram to remind the patient of the presence of such restorations and keep a copy in the notes.• The teeth will change colour with bleaching but the existing composites, veneers, or bridges will not change colour.• If it is subsequently necessary to make these the same colour as the bleached teeth, significant numbers of restorations may need to be redone.• White spots will become whiter in initial stages, but almost always revert.• Record in the notes that this has been discussed
PROTOCOL 4 Advise the patient that the necks of the teeth may take longer to lighten. If there is a lot of recession – must inform pt root surfaces may not bleach Temporise carious teeth and leaking restorations. Very old amalgam fillings may leave a dark purple colour on the bleaching tray. It is prudent to polish these restorations with conventional multibladed tungsten carbide burs before commencing. Bleaching should not be undertaken whilst patients are known to be pregnant or breast-feeding.
HISTORY (adapted from data in Haywood)Year Authors Innovation1799 Macintosh Chloride of lime is invented - Called bleaching powder1884 Harlan 1st Hydrogen peroxide use Used 35% HP inside tooth and suggested 25%HP with heated1958 Pearson lamp1961 Spasser Perborate sealed within tooth - "walking bleach" Thermocatalytic Technique - pellet saturated with suoperoxyl1965 Stewart and heated with an instrument inside pulp chamber. In office bleaching using 30% H2O2 and heat from bleaching1987 Feinmann light1989 Croll Microabrasion technique1989 Haywood and Heyman 10% CP used in trays overnight "Nightguard Vital Bleaching"1990 Bleaching products available OTC - contraversial ! Bleaching materials were investigated and the FDA called for1991 safety studies. Ban was lifted after 6months1991 Numerous authors Power bleaching using 30% HP and light activiation1996 Rayto Laser tooth whitening1997 Settembrini et al Inside-Outside bleaching technique1998 Carrilo et al Open pulp chamber with CP inside