- The BS of KIS Whitening
- 30% Safe for At-Home
- Pulpal Damage? – Avoid the Heat
- Leave Reservoirs Behind!
- RDH Corner – The ABCs of Whitening Sensitivity
- Get Out of the Bedroom!
- Limiting Liability
- Loma Linda – The Whitening Experts Speak!
The BS of KIS WhiteningKeep It Simple! The Basic Science of whitening, or Bleaching Science, has come to prove that, in tooth whitening as in most things, Keeping It Simple (KIS) is the very best medicine.The science is basic – carbamide peroxide safely and effectively whitens teeth. There it is. This has been recognized and accepted for over a decade by legions of patients. In the quest to find the best way to use carbamide peroxide, many ingredients and drastic modalities have been tried. Many of those have ended up complicating the issue but have served to help us learn more.Some theories have not fared well when subjected to the realities of Bleaching Science – reservoirs, super-thick gels, and “time-release” agents have been brought to bleaching by some whitening manufacturers all in support of long-term modality. Overnight or multiple hour treatments have turned out to be not necessarily in the best interest of the patient and are also not your best modality choice. It kept the stent in the mouth after the majority of the active ingredient was expended, allowing the gel to be swallowed, and continuing to contribute to unnecessary pain-producing tooth dehydration.More Bleaching Science – Dr. Drosman’s 1,400 patient stud y has proven that high-concentration, short-term modality is safe and effective for at-home use. Using 30% carbamide peroxide, the study showed dynamic results and superb patient compliance all with only 5% acute pulpal sensitivity. This success was achieved with no reservoirs, no fluoride, and no resin curing lamp. This modality achieved the fastest, most predictable results, hence, the most compliant and happy patients.
Read on and find out in more detail how Keeping It Simple and the Bleaching Science can help you focus your whitening practice with simpler procedures and more compliant and comfortable patients.
30% Safe for At-Home
A study by Robert M. Drosman, D.D.S., ” Whitening the Dentition with 30% Urea Peroxide” can be summarized as follows:
* 2,800 arches were tested from 1989 to 1999 with profound whitening and no detrimental effects.
* Multiple shade shifts were achieved in 93% to 97% of cases using two 20-30 minute treatments within 7 to 10 days.
* 30% carbamide peroxide has been tested in-vivo and has shown no soft tissue a berrations in accordance with the A.D.A. protocol for safety.
* 30% carbamide peroxide had no deleterious effects on oral tissue or body systems in accordance with the A.D.A. safety standards for in-vivo soft tissue tests.
* Undesirable one-shift color change and temporary dental sensitivity occurred at a frequency of less than 5%.
* Even 5 years after the initial treat- ment, only 4% of the cases displayed a color reversion of 2 shades.
* Uniform, predictable whitening of the dentition is safely attainable by increasing the bleaching agent 50%-100% over that whiach is presently commercially available (15% to 22% concentrations) with the added benefit of substantially quicker results.
Pulpal Damage – Avoid the Heat
Can whitening cause pulpal damage? A series of studies on pulpal damage indicate that some in-office procedures can damage the pulp, identifies the culprits, and points the way to avoiding the risks.
At risk are the in-office procedures that combine H2O2 and heat. H e=”font-size: xx-small;”>2O2 is absorbed more quickly than carba-mide peroxide allowing the peroxide to reach the pulp more quickly and in greater quantity. Pulpal enzymes are significantly inhibited by H2O2. Heat alone can cause pulpal damage. Howev er, the combination of H2O2 and heat is the real problem! The hydrodyn amic pressures of a H2O2 exposed pulp under heat can disrupt the metabolic pathway or damage biological membrane. It can evoke an inflammatory response that may result in pulp al necrosis and the need for future endodontic treatment.1
Heat can come from such a source as a resin curing lamp. Lamps are good for sizzle but are at risk of pulpal damage and do little for the actual in-office procedure. The heat does accelerate the whitenin g process but only a few minutes of time is actually saved over in-office non-heat chemical whitening.
There are other risks besides actual pulpal necrosis. Acute pulpal sensitivity is common during and/or after treatment when heat and H2O2 are combined. Why subject your patients to pain and pulpal risk?
How do you protect the patient and still have the ability to deliver the fast, in-office results patients demand? Using high-concentration carbamide peroxide is safe as less peroxide reaches the pulp. Use a waiting room carbamide peroxide (i.e. 44%) in a maxillary bleaching tray as a booster and send the patient home with a high-concentration (30% CP) at-home bleaching gel. It will deliver the fast, predictable, and safe results your patients deserve.
The fact is, it takes multiple in-office treatments, regardless of technique employed to achieve the equivalent of at-home whitening. If your treatment plan is strictly in-office, use 35% H2O2 without the lamp and keep the treatment time to multiple 3-minute paintings. This way, the patient will see the results without the risk of potential necrosis or post-op pain.
1. Bowles WH, Thompson LR, Vital bleaching: the effect of heat and hydrogen peroxide on pulpal enzymes. J Endodon 1986;12:108-12.
2. Bowles WH, Ugwuneri Z, Pulp chamber penetration by hydrogen peroxide following vital bleaching procedures. J Endodon 1986:13:375-77.
Leave Reservoirs Behind!
Abandon Superfluous Overnight Bleaching
Reservoirs sounded like such a good idea at the time. But, when Clinical Research Associates released the results of their 1997 study of the major bleaching materials, all the products had expired approximately 70% of the active ingredient in the first hour.1 Dr. Matis’ more recent study found a higher retention of the oxidizing agent studied. However, since the CRA study, most of the bleaching suppliers have been running to short-term modality. So why would we continue to use reservoirs?
Reservoirs take unnecessary lab time and may not be in the best interest of our patients. Overnight/multiple-hours bleaching is just not user friendly, making reservoirs the baggage of an outdated bleaching modality.
As pointed out by Rella Christiansen of Clinical Research Associates last November at the Loma Linda University, “The State of the Art 2000” panel discussion, an independent CRA study has found no data to support the contention of reservoir effectiveness. An identical conclusion was reached in another clinical study concluding, “. . . there are no statistically significant differences in those teeth whitened with tray reservoirs versus teeth whitened without tray reservoirs.”2
So, the evidence indicates the desired benefits are simply not realized.
Other researchers have known it for years. A Haywood 1997 article states: “There is no indication that the presence or absence of a reservoir-type spacer or similar foam insert has any effect on bleaching time.” 3
I believe that reservoirs lack benefits because the extra oxidizing material doesn’t reach the tooth surface. The additional material in the reservoir dissipates in the reservoir cavity instead of being absorbed into and activated inside the tooth.
The old-school method of reservoirs and overnight bleaching subject the patient to the swallowing of gel. The reservoirs provide more gel to be swallowed. Overnight bleaching then gives the patient a great deal more time to swallow the extra gel. Swallowing whitening gel is a questionable idea when the product contains KNO3.
With no reservoirs, nature’s methods are left to work their Basic Science, and your patients are at lower risk. Van der Waal’s forces create a seal between the tray and the tooth that holds the stent in place and helps resist saliva penetration (see figure 2 below). The minimal amount of gel is used. This way, regardless of how well the patient follows instructions, less gel is at risk of being swallowed. Dosage is .25 cc, the equivalent of 10 to 12 drops placed in the tooth indentations. Less gel equals less patient risk. Therefore, very little material is swallowed and the actual whitening process has the benefit of maximum oxidation per volume of gel. High concentration/short-session bleaching makes whitening teeth amenable to keeping bleaching as a bathroom modality. Put the gel in the tray, the tray onto the teeth, shower, dry, put on cosmetics/shave, take the tray out, expectorate, rinse, and voilá – timeless patient compliance!
The repeatable data in Bleaching Science has ushered out overnight modality. We can leave the rest of the overnight reservoir baggage behind, simplify our lab work, and lower the risks for our patients.
Why No Reservoirs?
1. Clinical Research Associates Newsletter, Tooth bleaching, state-of-art ’97, 21:4, 1:3 2. Bosma M, Bowman J, Dorfman W, and Soll K, Clinical evaluation of a tray fabrication design and effects on vital tooth bleaching. Hill Top Research, Inc., Miamiville, OH; 1:3 3. Haywood V, Extended bleaching of tetracycline-stained teeth. Cont. Esth. & Rest. Practice, Sep. ’97, 14:21
Have you ever had sensitivity when bleaching your teeth? Not fun is it? Whether you have or not, you already know you don’t want your patients to go through unnecessary discomfort. The fact is, sensitivity is a reality of tooth whitening for some patients regardless of the bleaching products or the concentrations used. Brushing up on the ABCs of bleaching sensitivity can help you better understand the:
A) symptoms, B) causes, and C) solutions, and can help you maximize your patients’ whitening comfort.
Start by identifying the actual symptoms.
Is this a case of soft tissue irritation or pulpal
Soft Tissue Irritation
Concentrations higher than 15% can cause soft tissue irritation. The symptoms are tingling or stinging of the gums or the appearance of small blanchings or tenderness. There are three causes of soft tissue irritation. The first is an overlapping tray. Care should be taken to trim the tray away from the soft tissue. The second is overfilling the tray, which is a common mistake of many patients. Instruct the patient to decrease the amount of gel in the tray. Less is best! The proper dose is a small drop in each tooth indentation for a total of only .25cc (10-12 drops). Finally, soft tissue irritation is often caused by food, floss or toothbrush cuts and abrasions. Such wounds need to heal before whitening.
The symptoms, causes and solutions for pulpal/dentin sensitivity include:
Symptoms may come in the form of a dull toothache or a headache. Using short-term modality (20 to 60 minute treatments) should avoid this problem. By the end of the first hour, the carbamide peroxide has been expended by approximately 70% 1.
Wear beyond that point does less bleaching and continues to keep the teeth coated with gel. Short-term modality allows rapid saliva re-hydration to quickly counteract the hydrostatic imbalance created by the H2O2 in the dentin tubules and enzyme systems in the pulp. One answer for patient discomfort is taking a break for a day or two and/or cutting back the treatment time.
When the patient has a history of acute pulpal sensitivity or is experiencing severe sensitivity, it is being caused by direct access to the dentin from recessed gums, enamel fractures, a chipped tooth, leaking margins, etc. The pain comes in the form of a jolt or shock from a single tooth. In these cases, a KNO3/Fluoride sensitivity toothpaste is recommended for u se tw o weeks prior to whitening and then throughout the treatment. Toothpaste is the safest way to administer KNO3, and it allows the KNO3 to adequately neutralize the nerve endings and the fluoride to reduce dentin orifices. A common pain reliever such as aspirin or ibuprofen is also a good strategy for acute sensitivity due to exposed dentin.
Whether the sensitivity is from soft tissue irritation or pulpal sensitivity, have the patient take a break in the treatments for a day or two to allow him/her to normalize. Then make the appropriate diagnosis and adjustment and continue treatment. Those who experience discomfort will most likely not have the prior magnitude of discomfort.
Sensitivity is based on the patients’ perception, which can be positively affected by you. Helping the patients categorize the sensations that are experienced during whitening treatments can help them put what they feel into proper perspective.
Remind them it is safe. Tell them that bleaching gels whiten much like cosme-tologists color or lighten the hair of millions of people. Cosmetologists use 10% to 40% hydrogen peroxide, while dentists whiten teeth with at-home strengths from 3.3% to 10.5% H2O2. Literally millions of people have had their teeth safely whitened – a magnitude of safety rarely enjoyed by other cosmetic procedures. Carbamide peroxide is prescribed to treat gums and combat gingivitis. Under professional supervision, whitening is safe and effective.
Inform your patients what to expect. Keep in mind that 15% to 20% of your patients will experience sensitivity wearing the tray alone. Another 15% on top of that will experience sensitivity with a placebo in the tray.2
1. Clinical Research Associates Newsletter, Tooth bleaching, state-of-art ’97, 21:4, 1:3 2. Haywood -See Footnote 1, Pg. 3
Victoria DaCosta, RDH, is a practicing Dental Hygienist, innovator, and President of GumAerobics — a fun & simple treatment for gum disease. Visit her website at www.gumaerobics.com, or E-Mail: firstname.lastname@example.org. For more information, call 888/373-4000.
Get Out of The Bedroom!
Patient compliance is the biggest barrier to bleaching success.
Here’s a tip to give your patients that will help assure their whitening success:
Tell your patients to simply work the treatments into their daily bathroom routines, morning and night, using 30% carbamide peroxide with the fast and easy 20-30 minute bleaching modality.
Here’s how it works:
The patient goes into the bathroom, brushes, puts a small amount of gel (10-12 drops) into a non-reservoir stent, inserts the tray, and then goes on with the usual bathroom routine (shower, shave, preparing hair and makeup). The patient then removes the tray, expectorates, rinses the mouth and tray, and is finished.
This way, the patient doesn’t have to find a special or separate TIME for bleaching each day. Instead, the bleaching session just becomes an additional part of his/her daily bathroom routine. Try it yourself and see how easy it is to take whitening out of the bedroom and put it into the bathroom — where it really belongs.
The FDA, the ADA and YOU!
By Rodney Ogrin, DDS
In a business climate where patients can sue their dentists over a toothbrush, thoughts of limiting liability are prudent. What kind of exposure do you have regarding the use of bleaching gel? How do you play it safe? What are acceptable risks? Only you can answer these questions for yourself, but these are some of the issues on the table to consider:
* The ADA has accepted only 10% carbamide peroxide for at-home use.
* Because a company has an ADA approved product does not mean their products with KNO3 in them or their higher concentrations of carbamide peroxide (11%, 13%, 15%, 16%, 20%, 22%, 30%) have been ADA accepted.
* In my experience, most dentists are not postponing the use of higher concentrations until the ADA finally gives their blessing, but have already moved to the efficacy and predictability of the higher concentrations.
* Higher concentrations of carbamide peroxide have been used successfully for a decade and, to my knowledge, without a single lawsuit.
* After ten years of whitening, there are no studies indicating that higher concentrations of carbamide peroxide have a negative effect on enamel or the pulp.
* The FDA classifies carbamide peroxide for teeth whitening as a cosmetic, which limits the testing requirements and regulations.
* The ADA traditionally takes a relatively long period of time to sort out such seemingly conflicting issues.
Dentists are left to make their own product selection decisions. Based on what we now know, the acceptance of higher concentrations looks good – as they are backed by years of safety and success.
1. Oral Health Care Drug Products for OTC Human Use…, Federal Register Vol. 56, No. 185, 21 CFR Parts 356 & 369, Sep. 24, 1991, 48302:48347
Loma Linda – The Whitening Experts Speak!
On November 14, 1999 a panel of tooth whitening professionals gathered at Loma Linda University for a discussion on “The State of the Art 2000.”
Loma Linda was the first national symposium on the subject of tooth whitening and served to eliminate bleaching myths and bring out the truths of Bleaching Science.
The panelists included:
* Van Haywood, DMD, Medical College of Georgia
* Rella Christiansen, PhD, Clinical Research Assoc.
* Chakwan Siew, PhD, ADA
* Yiming Li, DDS, MSD, PhD, Past ADA, now at Loma Linda University
* Ralph Leonard, DDS, Chapel Hills, NC
* James Dunn, DDS, Loma Linda University
* Bruce Matis, DDS, Indiana University
* Carlos Munoz, DDS, Loma Linda University
Some KEY ISSUES raised by the panel include:
* Lack of data to support the contention that reservoirs whiten better
* The assertion that all tooth whitening products work
* Skepticism for the curing light/35% H2O2 modality due to lack of data and an increase in post-op pain
* Questions about whether activators do or do not whiten better
* Concerns that heat can damage the pulp
* Recognition that canines are more difficult to whiten and can best be addressed with higher concentrations.