Tooth-whitening systems provide several options.
Robert L. Ibsen, DDS, OD, FACD, FICD
More dental professionals are recognizing the opportunity that tooth bleaching offers. The cosmetic procedure is becoming a part of the total treatment planning for patients. Indeed, bleaching is proving to be an efficient modality to whiten teeth in a safe, fast and effective manner. With new techniques and flexible treatment systems, patients are discovering that whiter teeth and brighter smiles can be theirs without discomfort and at surprisingly little cost.
The growing acceptance of bleaching has evolved over the years as different methods have been used to remove stains from tooth surfaces. Some of these methods have included applications with concentrated hydrogen peroxide (30 to 35 percent) solution and heat, or etching tooth surfaces with phosphoric acid, followed by the use of a concentrated hydrogen-peroxide solution. In addition, abrasive materials and instruments have been used to remove surface discoloration.
Recently, newer techniques, using bleaching agents of low concentrations, have been advocated. In fact, even though low peroxide-containing compounds have been used for bleaching since 1893, over-the-counter bleaching kits and toothpastes containing peroxide have been available only since 1989. Presently, most techniques use some form of hydrogen peroxide - though with different concentrations and with different application techniques.
In general, three types of bleaching systems are used in dental practices today: in-office or chairside, at-home with a mouthguard, and whitening toothpastes.
In-office systems are performed at the dental chair using high concentrations of carbamide peroxide or hydrogen peroxide. The compounds are applied directly to the teeth for varying periods of time.
These systems are fast-acting, performed by a professional, and generally command a higher fee, since patients are able to have the treatment completed in one or more in-office visits. The gingival tissues are adequately protected with a paint-on dental dam or rubber dam. Depending on the product used, the active ingredient may be placed placidly, used in a heated form, or used with a light source.
Over the last year or so, lasers have been used for bleaching teeth. However, the laser system is very expensive, and the office staff must be trained in its use. The procedure is time consuming, since the mouth has to be protected from the 50-percent peroxide that is used, and patients need to be pre-bleached prior to use. There have been reports of patient discomfort after the bleaching process. The question that needs to be answered is: Is it the laser or the 50-percent peroxide?
At-home with a mouthguard
Most at-home bleaching systems use 10 to 15 percent carbamide peroxide as the active ingredient, along with thickeners and flavorants. The carbamide peroxide breaks down after coming in contact with saliva to form hydrogen peroxide and water. The hydrogen peroxide further breaks down to form nascent oxygen, which functions to remove tooth discoloration.
Patients apply this type of system with a prefabricated, custom-fitted mouthguard made by the dentist. The mouthguard is worn anywhere from one hour a day to overnight. Professional supervision provides proper case selection, the safety of professional monitoring, and the effectiveness of a properly-fitting, professionally-fabricated mouthguard for delivery.
One product now on the market is designed to combine both an in-office chairside and at-home process in one system. The patient begins treatment with an in-office procedure and then receives at-home bleaching gel, which is to be used in a mouthguard for one hour a day for six days. At the end of this period, the patient returns for a final in-office procedure. This system reportedly provides excellent results, is fast, and has been well-accepted by patient and doctor alike.
Bleaching toothpaste has been described as the simplest and easiest way to whiten a smile and serves as an intermediate-level alternative for those patients who do not feel they need, or want to bother with, a mouthguard. This approach also accommodates patients who are not yet ready to make the financial commitment to in-office or professionally-supervised at-home bleaching.
Just because a toothpaste is called "whitening" does not necessarily mean that it is capable of actually changing tooth color. At one end of the spectrum is the toothpaste with a high level of abrasion that merely removes stain and plaque. At the other end of the spectrum is the product that is low in abrasion, yet has superior ability to not only remove stain and plaque but whiten teeth by up to two shades when used alone.
Some manufacturers have further confounded the whitening issue by making statements that their brands of toothpastes whiten teeth because they remove surface stain.
Vital tooth bleaching is gaining wide acceptance, and several effective delivery systems are now available to provide patients with whiter and healthier smiles. It is imperative that patients are made aware of the new techniques and procedures. Use this gateway, doctor, to revitalize your dental practice for the benefit of all of your patients.
Dr. Ibsen, who practices in Santa Maria, CA., has served as expert examiner for the California State Board of Dental Examiners and has lectured on esthetic dentistry throughout the U.S. and abroad. His memberships include the Pierre Fauchard Academy and the American College of Dentists. Dr. Ibsen has been published in various dental journals and is author of a textbook, Adhesive Restorative Dentistry. He has been active in the development of numerous dental products that preserve, restore and enhance tooth structure. He holds 36 patents for such products, and in the past 20 years has made them available to dentists worldwide.
Why patients should pursue advanced bleaching options
Even though bleaching is becoming more highly regarded by dentists who perform or dispense the procedure and patients who receive treatment, most practices rarely bleach the teeth of more than 2 to 5 percent of their patients. How do dentists motivate patients to accept the more advanced bleaching techniques when inexpensive whitening toothpastes are available? Here are some points to consider:
- A dental professional can maximize the bleaching process for patients either with a combination of in-office and at-home procedures, or one of the two alone. Patients receive at least twice the bleaching results with an at-home system when compared with just a bleaching toothpaste alone.
- Patients have to be made aware of the fact that dentist-administered bleaching is a safe, non-invasive treatment, and the least expensive of all cosmetic procedures.
- Dentists have to convey to the patient that the diagnosis of his or her condition is an essential element in the whitening process.
- Patients have to be made aware of the fact that the custom fit of a professionally-fabricated mouthguard enables them to receive the optimal amount of peroxide with the best results.
As a rule, people do not bleach their teeth because they feel their teeth "don`t look all that bad," or the procedure takes too long, or the cost is too high. The cost and appearance issues may be rectified by offering a bleaching toothpaste dispensed through the dental office. Again, patient motivation is highly important.
Patients may be educated through audio or video tapes, through interactions with hygienists during hygiene or recall visits, and with subliminal information for bleaching displayed in the office. At the same time, many dental offices have instituted policies to help change patients` perceptions and motivate them to accept bleaching. Some of these offices charge patients only for the fabrication of custom mouthguards ($150 per mouthguard) and provide the whitening free of charge. In some cases, patients receive a chairside treatment upon completion of a routine prophylaxis for a nominal charge.