High concentration vs. Low Concentration, Overnight vs. Short Treatments, Reservoirs vs. No Reservoirs, KNO3 vs. no KNO3: there are many contradicting choices about at-home whitening out there, yet these decisions must be made. When the facts and science of at-home whitening are held up to your practice’s and your patients’ goals, the case for high concentration, short-treatment whitening is hard to dispute. When choosing an at-home whitening modality, here are the questions and answers a dental office can consider:

What is safe?
No patient has suffered any harm from high concentration at-home whitening beyond minor blanching of soft tissue. Studies show there is no negative impact on enamel, dentin, or pulp. Inadvertent blanching is most often reversed within an hour.

Safety issues of possible concern are the use of unnecessary techniques and chemicals. For example, why use KNO3/fluoride in support of leaving bleach in the mouth longer than its naturally effective period as the majority of active ingredient is expended within the first hour?1 The use of curing lamps/heat in whitening has serious safety questions2. The use of reservoirs has not proven to improve the effectiveness of whitening and tends to promote the swallowing of more gel.

Sensitivity can be an issue for some patients. Most cases of acute pulpal sensitivity, which occur in a small minority of cases, are exacerbated by the dehydrating effects of long treatment times. The use of high concentrations for short treatment times of under an hour produces the fastest results and reduces dehydration and the frequency of pulpal sensitivity. For example, Drosman’s 10-year, 1,400-patient study using an at-home 30% c.p., found only 5% acute pulpal sensitivity due to the reduced treatment time. Access to the dentin and treatment time is the key contributor to sensitivity -- not the percentage of carbamide peroxide. There is no reported difference in sensitivity between 10% and 30%.

With lower concentrations, 10% requires substantially more wear time to achieve the same whitening. More wear time means more discomfort and decreased patient compliance, as most people don’t like to wear a stent. Further, more wear time means more dehydration of the teeth, a chief contributor to sensitivity.

What is most effective?
The most effective concentrations are the faster acting percentages. High concentrations get the job done fast and give the patients the fast gratification that keeps them engaged with their treatment. When patients see fast, predictable, notable results, they stick with the treatments. Patient compliance is all about patients seeing fast results.

What is the most practical?
The biggest practical difference for the patient is that high concentration whitening can be taken out of the bedroom and put into the bathroom. Whitening sessions now need to be only 20-30 minutes long, making them fit easily into daily bathroom routines of showering, shaving, applying makeup, etc. This way, whitening is much less invasive on the time of the patient -- and this in turn supports maximum patient compliance.

What liability am I incurring?
Some dental authorities have been pressing for the use of only 10% as approved by the ADA. However, where is the liability? A majority of dental offices have been prescribing 15% to 22% for years. Yet, higher concentrations of carbamide peroxide simply have not resulted in liability problems. Where are the lawsuits? Why fix something that isn’t broken, especially when it’s not in the best interest of your patients?

While there have been a plethora of studies proving the safety of carbamide peroxide for whitening, I’ve seen no studies on the safety of KNO3 for whitening. There are also some very legitimate potential health risk questions that could be raised, such as nitrosation in the digestive system, resulting in potential carcinogenicity.

What is the most cost-effective whitener?
High concentration at-home whitening achieves the most effective results for the patient and incurs the lowest cost to the dental office. With high concentration gel and no reservoirs, more whitening can be achieved per volume of gel, hard costs are maximized, lab time is reduced, and patient satisfaction is greatly increased. Now that’s cost effective!

When you add it all up, high-concentration, short treatment time modality is the clear choice for your patients and your practice.

1. Clinical Research Associates Newsletter, Tooth bleaching, state-of-art ’97, 21:4, 1:3
2. Bowles WH, Thompson LR: Vital Bleaching: the effect of heat and hydrogen peroxide on pulpal enzymes. J. Endodon 1986;12:108-12

Wild Cherry, Banana, Peppermint Cream, Melon, Mint - by offering your patients such flavor choices, are you not sending them the message that tooth whitening gel is okay to swallow? The fact is, BLEACHING GEL IS NOT A CANDY! Carbamide peroxide is a dental chemical for the purpose of bleaching teeth. Chemical bleach is not meant to be savored or swallowed. Why would you want to encourage your patients to swallow gel by asking them what their favorite flavor is?

The taste is there to act as a warning. When a patient tastes the gel, it should only be as an indication that the tray was overfilled. A single, standard, sharp mint flavor achieves this end nicely. The patient then knows to spit the gel out and reduce the amount of gel in the tray next time.

Stocking all these flavors does your office no service as well. If you employ different percentages, what sense does it make to have to stock an array of gel in different flavors for each percentage? This can ultimately lead to wasted inventory, shelf life problems, and orphaned stock. Keeping it simple almost always pays off; one flavor, one message – less is the best.

Multiple flavors was an idea in support of an outdated modality. Reservoirs defeat van der Waal’s Forces and allow more whitening material to be tasted and swallowed. Overnight bleaching allows gel to escape the tray over multiple hours of diminished active ingredient wear time. Swallowing gels that contain KNO3/fluoride is an especially questionable practice. Short-term modality with no reservoirs minimizes the escape of gel from the tray via van der Waal’s Forces, therefore, limiting the opportunity for a patient to taste material.

The taste of whitening gel is an indication of the need to make downward dosage adjustments and not something to be encouraged with multiple candied flavors.

Whiten one arch at a time or both arches at the same time? Every dental office that provides whitening services has to answer this question. And, with faster-acting, higher concentrations of at-home whitening becoming more the norm, the question only becomes more pertinent. I have heard good arguments on both sides of this issue. I also have my own, strongly held opinions. Here, I’d like to present both arguments and let you decide for yourself.

Dual Arch
The idea here is to give the patient the choice. Why take twice as long to bleach both arches for the same results? Should we not give patients credit for making their own informed decision?

With high-concentration, at-home whitening such as the 30%, the results are more quickly noticeable. The patient and the patients’ family and friends are more likely to see the difference. There is always the proper use of a shade guide for backup for those few nay-sayers.

Additionally, the short wear time prevents previous concerns of possible TMJ aggravation from doing two arches at once.

Doing both arches eliminates any confusion about which one is best, the upper or lower, as the whitening that is achieved is the result regardless. There’s also less confusion about when to stop bleaching the second arch.

Single Arch
The idea here is for the patient to be able to see the difference between the upper and lower arch. Even if you’re using 30% and getting fast results in just a week, some patients question the actual difference without the contrast of comparing arches. When I’m in an office that whitens both arches at once, we sometimes get complaints. When we do only one at a time, the complaints stop. If you choose to whiten one arch at a time, give the patient only the upper arch tray to start, along with the gel needed for the first week. Set a recall appointment in one week. If there are any problems with sensitivity, chronic overfilling of the tray, etc., you’ll know it soon. If you are using a fast-acting gel such as 30%, a week is more than enough time to see dramatic whitening and contrasting results. Recall costs almost nothing in chair and administrative time, yet adds great value to the whitening service, helping set your service above the growing whitening options that continue to be made available.

Another advantage of the one-arch system is, the patients’ friends and family will also be able to see the contrast. 30% treatments can be performed in the bathroom, 20-30 minutes each. So, what difference does it make if it takes one or two weeks? The best part of the one-arch system is, it supports the professional value of your whitening service. Instead of leaving patients with a nagging question of whether there actually was a difference, they’ll have strong visual reinforcement that your professional value is high and worthwhile. This is no small thing! Instead of questioning your next bit of advice, you will be given the professional validation you always deserve!

With all the options and rhetoric out there for in-office whitening, it has become difficult to know which procedures are hype and which methods provide meaningful value. Here are some guidelines to help you put the realities of in-office whitening into perspective so you can best represent the interests of your patients and your practice.

• Non-vital tooth whitening – Using 35% H2O2 on a non-vital tooth can be helpful during and after endodontic procedures. The H2O2 can be used from inside and outside the tooth. This is a great way to take that gray out of a dead tooth.
• Special event whitening – If you have a patient who has a special event coming up within a day or two, a single, in-office treatment can provide a shift change that will give the patient just the confidence he/she desires. However, with anything more than a day or two to go, high concentration at-home whitening can do more, faster.
• Booster whitening – Some offices like to give their patients a boost into their at-home whitening treatments. Many will use 44% carbamide peroxide for the upper arch as a waiting room treatment. It can give the patient an extra boost of confidence.

In-Office Don’ts

• Replacement for At-Home Whitening – In-office whitening takes too much chair time, results are simply too minimal, and costs too much for the office. In-office procedures cannot be an economical substitute for the patient or the practice for at-home whitening. With the availability of fast-acting, high-concentration at-home whitening gels, at-home whitening by far achieves maximum whitening with the most predictable and longest lasting results possible. Who can’t afford a week of whitening during bathroom hours?
• Use of lights – The combination of heat and H2O2 is a possible endodontic accident in the making. There are studies and experts who have raised far too many real concerns about this combination.1 Further, there is little to no indication that any real advantages are realized by adding the use of a curing lamp, as 35% H2O2 will achieve the same or similar results on its own.
• Whatever you do – Don’t miss “The Case for High Concentration” (Page 5) -- How high concentration whitening at home produces fast and predictable results.

1. Bowles WH, Thompson LR: Vital Bleaching: the effect of heat and hydrogen peroxide on pulpal enzymes. J. Endodon 1986;12:108-12

A recent trying personal experience has led me to a message I feel compelled to share with my fellow dental professionals. Last year it was discovered that I had prostate cancer and that my time in this world could be abruptly cut short. Thanks to an early detection, some good information, and a successfully implemented treatment therapy, I’ve overcome this threat to my very life and been given the gift of time. The hope that my experience may save another has driven me to share my experience with you to motivate you to communicate early detection of mans’ Achilles Heel, prostate cancer, to your 40-year-old and older male patients, whenever you can.

The fact is, prostate cancer is a poorly understood killer that claims up to 50,000 lives a year. Many more than that suffer incontinence and impotence due to radical treatment procedures that could have been avoided by early detection. Early detection can provide the patient with conservative treatment choices without the devastation of loss of life or bodily functions. Every man should become aware of any family history of prostate cancer. Regular testing should be routine after the age of 40. A PSA test takes only a few minutes.

Need additional motivation? It’s all about time.

If you are a male dentist, think of the precious time you now spend with the ones you love: your wife, girlfriend, children, family, friends. Don’t cheat them out of the time they expect to spend with you. Think of how you are needed in your practice, by your patients, by your family and by your community. A lot of people are counting on your having this time.

As a health care professional, you have the opportunity to share this message with others, the other male friends and family in your life, and as appropriate, your male patients. It’s a sign of caring. It takes no time and can serve as simple, friendly chit-chat.

So, ask yourself . . .don’t you have the time to stop this needless killer and ensure that you have the time you and those you love deserve?

So, you or someone on your staff has a whitening question. Where can you turn? There are some powerful resources out there from which to choose.

To start, there are the top service people at Life-Like. With them, you can find instant personal service as well as your bottom line for answers.

When you get Customer Service Manager Jerry Hernandez on the phone (pictured above) you’re talking to a literal encyclopedia of bleaching information. Mr. Hernandez has fielded every kind of whitening question for more than 4 years. Chances are, he can’t be stumped. But, if you were to perplex him, he can always turn to a broad base of highly experienced dentist and hygienist consultants to whom he has access.

Then there is Customer Service Representative Aimee Ogrin (see the cover). She grew up with whitening. She too has answered nearly every question a dentist, hygienist, or dental assistant could ask about whitening. You may recognize her from past Life-Like publications. Aimee is an excellent whitening resource. Just like Jerry, Aimee will take your questions to heart. They’ll have or find your answer to whatever whitening question you may have, no matter how general or technical. The key is the personal caring they show for every question, issue, and customer.