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Newsletter – 1st Quarter 2001

This Issue:

  • Reference Guide Introduction
  • At-Home Whitening – Choosing Percentages
  • In-Office Whitening – Modality Instructions
  • Stent Fabrication – A Step-By-Step Illustrated Guide
  • Sensitivity Chart – Symptoms, Causes, & Solutions
  • Patient Instructions – A Teacher’s Guide
  • Whitening’s Turbo Boost! Dual-Arch Whitening
  • Mini-Kits – Providing Pricing Options

Annual REFERENCE GuideThis is the first annual Whitener Reference Guide. The other quarterly issues of the Whitener cover the currently hot, pertinent whitening issues, in depth.The Reference Guide is different — more basic, more timeless. It contains hard procedural information you and your whitening staff can use all year long. It’s a handy guide — with careful, step-by-step instructions, reference tables, comparison charts, and lots of useful, practical tips, and hints. They are things that make whitening even easier, and more effective. To go a step further, on the red check marks on the printed version you’ll find at the end of each story reference a specific web page with additional helpful links or information. Check it out.If you have not received your hardcopy version of the Whitener Reference Guide, give us a call now and we’ll send one – 800-543-3545.
At-Home Whitening Reference
At-home whitening using carbamide peroxide is, by far, the best all-around modality for whitening teeth. Ten percent carbamide peroxide was the first whitener introduced into the mainstream of dentistry. Percentages have risen significantly as now 30% has been proved safe and to produc e the fastest and most predictable results. Many dentists continue to use the lower percentages for varied reasons. Here are a few guidelines to help you when selecting the best percentage for individual patient cases and your practice.

10%Treatments: Two Daily 1-Hour
Common Use: Whitening, Cleaning & Debriding
Carbamide peroxide was first found to whiten teeth while being used in low concentrations to treat periodontal disease. The use of carbamide peroxide in whitening trays has helped bring the practice back to it’s periodontic roots. By trimming the trays so that it overlaps the gingiva and using 1/2 ccs of material, studies show the treatments clean and debride the gums as well as provide maintenance level whitening.

Treatments: Two Daily 45-60 Min., Days: 18-26
Common Use: Conservative Whitening. Not long ago, 15% C.P. was the highest selling percentage for many manufacturers. These days, 15% has been left in the middle as the higher percentages have proven themselves safe and more effective. It does still have a place in your practice. Fifteen percent can be the right choice for a patient who you believe will not follow dosage instructions and may likely overfill of the tray and cause blanching.

20%Treatments: Two Daily 30 Min., Days: 14-20, Use: Fast Whitening, Minimum Soft Tissue Irritation Twenty percent also has been caught in the middle. It is not likely to cause blanching, but can cause some soft tissue irritation. It whitens well but requires longer treatment sessions and more treat ment days than its 30% cousin. Twenty percent is also a good choice for patients who want fast results but who you believe may have trouble following directions or who may have oversensitive soft tiss ue issues.

30%Treatments: Two Daily 20-30 Min. Days: 7-10, Use: Fastest, Most Predictable Some practices, such as the renown clinician Dr. William Strupp, are now whitening all their patients with 30%. When you have a patient who wants the fastest, most predictable results, 30% is the best route. Dr. Drosman’s 1,500 patient study has shown that 30% is safe. Patient compliance is a major factor
in treatment effectiveness and satisfaction. The fast, predictable results of 30% keeps the patients involved and engaged and
makes dual arch whitening an overwhelming advantage for your patients whose time is precious.

In-Office Whitening Reference

Presented here are three In-Office modality options with summarized instructions for each. Included are:

1. Waiting Room Directions – 44% Carbamide Peroxide
2. Vital Directions – 35% Hydrogen Peroxide
3. Non-Vital Direction – 35% Hydrogen Peroxide

The table is a guide to help you identify the best option for each case. Al though at-home whitening is usually the best option for most patients, i n-office whitening has it place. The procedures are as follows:
In-Office Table

Waiting Room Directions

Use in a stent for the UPPER ARCH ONLY. It is used in situations where a patient needs a psychological boost to help him/her to follow through on the total bleaching program, or needs an immediate reduction in staining as a prelude to at-home bleaching.

* Form a stent on vacuum-former and carefully trim it off the soft tissue.
* Express evenly about 1/4 cc of material into the tooth indentations.

* OPTIONAL: Evenly disperse two drops of #9 ACCELERATOR over 44% bleaching material in stent.
* Place stent. A small amount of material may foam out. Wipe excess from labial vestibule with a dry 2X2. Wait about 30 seconds and wipe mucosa again with slightly moist 2X2. Place dry 2X2 in labial vestibule to further prevent gel from contacting soft tissue. Le ave passively in patient’s mouth (in dental chair or waiting room) for up to 30 minutes.

Vital Directions – 35% Hydrogen Peroxide

* Use ap propriate protection:
o Patient: eye wear, rubber dam muco protectant, and ligation
o Staff: Gloves, eyewear, gown
* Clean the teeth: Pumice or prophy paste, wash and dry.
* Lightly paint teeth with #9 Enhancer.
* Bleach teeth (3 min. 5 times is considered one treatment).
* Express approximately 1/ 2 cc into dappen dish.
* Use fine brush to cover:

1. labial
2. incisal – lingual surfaces.
3. EXCEPTION – With paint-on dam – cover facial surfaces only.
4. NOTE – do not etch prior to bleaching.

* Remove bleach:

1. Suction – use small surgical tip.
2. Alt. – Wipe incisally w/dry 2×2.
3. Rinse.

* Remove soft tissue protection.
* Recall; 4 – 5 days post treatment, evaluate for potential additional treatment.

Non-Vital Direction-35% Hydrogen Peroxide

I. Check endodontics –
A. Radio-graph
B. Do not bleach if negative signs or symptoms

II. Protect soft tissue

III. Open tooth:
A. Remove discolored dentin
B. Reduce gutta-percha 2-3 mm below gingival margin.

IV. Clean the tooth (OPTIONAL – Chlorhexidine soap with or without pumice)

V. Seal gutta percha to prevent micro-leakage with glass ionomer or bonded composite (white).

VI. Bleach the tooth (internal and external)
A. Bleaching Gel

1. Thin coat of #9 Enhancer inside and outside (optional)
2. Fill chamber, cover external surface
3. Repeat every 3 minutes for 5-10 applications (20-40 minutes total treatment time)
4. Temporize or seal permanently.

B. “Walking” Bleach (optional) Place equal mixture 35% Hydrogen Peroxide gel and sodium perborate, or 35% Hydrogen Peroxide2 gel only. Seal with composite. Reappoint in 2-5 days.

C. Optional combine — A, then B

VII. Place final restoration after etching prepared surfaces (both internal and external).

MORE INFORMATION
Check out these links for further information about these subjects:
44% Carbamide Peroxide Instructions
44% Carbamide Peroxide Syringe Delivered
44% Carbamide Peroxide Bottled Gel
35% Hydrogen Peroxide Gel Syringe Delivered
35% Liquid Hydrogen Peroxide – 1 Oz Bottle
No. 9 Bleaching Enhancer
How to Make an Optimal Stent
By the Numbers . . . Step-by-Step

Document the patient’s initial tooth coloring. Take a photo that includes the shade guide and record the shade number to establish a baseline. This will provide both you and your patient with a good point of reference.

Fill the impression tray with impression material. The material should come to the top anterior of the impression tray. Use an impression material dispenser or mix as directed by the material’s directions.
Note: Do not use block-out or die-spacer to ensure a tighter seal. Instead, allow maximum whitening per unit dose, and minimize the swallowing of gel.

Take the impression — Push the impression tray over the teeth until the material is covering the full depth of the teeth. Hold it carefully without movement for 30-50 seconds to allow the material to set. Remove the tray carefully by leveraging it off the molars first. Rinse and wrap the impression in a damp paper towel. Let it set until it becomes firm.

Mix the stone and pour the cast — Moisten the impression with water and then shake it off. Carefully flow a small amount of stone into the tooth indentations using a dental spatula. Use a vibrator to work the bubbles out of the impression material and ensure bubble-free margins. Allow the stone to harden.

Prepare the model – Soak the model in water for easiest separation. Remove the stone model from the impression. Grind down the base of the model so the central incisors are pointing upward in a 90° angle from the floor of the vacuum machine.

Put the model onto the vacuum machine. Both arch models can fit, but you may choose to do just one at a time.

Select the EVA and insert the sheet into the vacuum machine — .040 is the standard — or use .080 for bruxers. Clamp the sheet down.

Engage the vacuum machine heater to heat the EVA. Allow the EVA to sag a minimum of 2 inches. The lower the sag, the thinner the tray. Lower the EVA onto the model until the EVA bracket is fully down into place.

Engage the suction for 15-20 seconds to ensure a good form. Push the heating element aside and, with moistened, gloved fingers, immediately apply labial lingual pressure three times from cuspid, lateral, central, lateral, and cuspid.

Allow the tray to sit on the vacuum machine for a few minutes to cool. Then remove model and stent.

Trim away the excess EVA.

Use a ballpoint pen to trace a solid line along the gingival margin as a guide for trimming.

Trim the tray with a pair of small curved crown and bridge scissors to insure that the tray will not overlap the soft tissue.
Optional: Flame the EVA lightly with a laboratory torch to remove any rough edges.

Stent Instructions 14Run the stent under cold water using your fingers and fingernails to rub off the pen ink.

Stent Instructions 15
Once the tray is trimmed, check the fit by re-applying the tray to the model.

Stent Instructions TipIf a stent sags open and fails to close with a tight fit, you’ll be glad to know that there’s an easy fix:

* Hold the stent under hot tap water for 5-10 seconds to make the material pliable.
* Squeeze the stent between your thumb and second finger. Use your index finger to push the middle of the stent into place.
* Holding it in place, run cold tap water over the stent for 15-20 seconds.

MORE INFORMATION
Check out these links for further information about these subjects:
Support Material – EVA options and more
Leave Reservoirs Behind! – An informative article

Sensitivity Reference

Sensitivity Chart

More Information
The ABCs of Whitening Sensitivity – An informative article

Patient Instructions
A Teacher’s Guide
Choices – Give the patient well-informed choices. When considering the percentage of c.p., single or dual-arch whitening, a well-informed patient who is involved in the prescription process has the greatest chance of achieving whitening success. The key is to involve the patients, give them a sense of control and participation. Many of today’s health consumers are more discerning, demanding, and capable of playing a larger role in their dental health.

Safety – Let the patient know the procedure is safe and review all safety issues. Explain to the patient this is similar to the hydrogen peroxide with which they wash out their mouth. Let them know that carbamide peroxide has been used to professionally whiten teeth for over a decade and has been proven safe and effective. When using over 15%, talk to the patient about soft tissue exposure and the importance of following instructions to prevent overfilling the tray.

Establish Expectations – Let the patients know what to expect during the process of whitening. Talk to the patients about blotching/hypocalcification and how it will whiten out as they continue the regimen. If you are using 30% and doing Dual-Arch whitening, explain to the patients they will not have the frame of reference but to ask friends and family for reference. Talk to the patients about patient compliance and how to stay with the procedure.

Document – Take a before picture, using the form in your Rx Kit. Record the initial vita-shade number on your patients’ charts.

Recall – Optional – Bring the patient back in one week. By that time, the patient should be seeing results and any issues that might prevent successful whitening can be addressed during this visit.

DemonstrateDemonstrate – Show the patients specifically how to open and seal the seal-syringe. It’s important to stress to the patients how important it is to use only 1/4cc of material. During the demonstration, make the drop into each indentation as small as possible, and repeat three times. Less is best, only use small drops… This helps drive home the point and will stick in their memory.
More Information
Check out these links for further information about these subjects:
Patient Instructions – Specific patient instructions for syringe delivered and bottled material.
Patient Q & A – Patient common questions and answers
Whitening’s Turbo Boost!

Tip – The speed of 30% C.P. makes practical Dual-Arch Whitening a reality. Patients see results fast enough to preclude the need for direct arch-to-arch comparisons, and treatment times are short enough to avoid possible issues of TMJ, discomfort, or boredom. So patient compliance goes UP! 30% may not be for everyone, but most patients appreciate having the choice.

See also 30% Safe for At-Home Use – an informative article, and 30% Product Information.

Mini-Kits Provide Pricing Options

Mini-KitJust for reference, not all whitening cases require a full whitening kit. Mini-Kits contain just half the material of the full kit and this is enough material to handle many whitening cases. Mini-Kits come in strengths of 10%, 15%, 20%, and 30% . . . and come with every-thing else you need, including the stent case and a zippered tote. Mini-Kits provide you the opportunity of offering special pricing to your patients who need less material for lighter cases, touch-ups, or cleaning & debriding (with the 10%).

See also Mini-Kits product information