What’s real and what’s not? Myths about sensitivity in professional tooth whitening abound. Here are the myths and the facts to consider:
Fact: The label, “zero-sensitivity,” is a misnomer. Double-blind clinical studies of nightguard bleaching products that claim zero-sensitivity have shown that sensitivity occurs in 55% to 75% of treatment groups. The placebo groups also experienced between a 20% and 30% rate of sensitivity.1 Sensitivity is a reality of tooth whitening that has no silver bullet. Managing it starts with knowledge of how to best utilize carbamide peroxide treatments.
Myth: Lower Concentration = Less Sensitivity.
Fact: Lower concentrations take longer to work and, therefore, require longer wear time. Longer wear time means the teeth are subjected to the dehydrating effects of the gel for longer periods. The short modality of high concentration offers lower sensitivity. With treatments of only 20-30 minutes, At-Home 30% maximizes rapid whitening due to the high oxidative concentration. Re-hydration can occur before the hydrostatic imbalance (the pulpal mechanism that elicits pulpal sensitivity) reaches the threshold that creates pain for the patient. Furthermore, Dr. Drosman’s 1,400 patient study using At-Home 30% showed an amazin gly low pulpal sensitivity ra te of less than 5%. Dr. Michael Miller of Reality supports the high-concentration approach, “I believe higher concentrations are going to be the major trend in home bleaching . . . Sensitivity is a non-issue if you follow the manufacturer’s directions.”2
Myth: Overnight Bleaching.
Fact: Overnight bleaching can lead to increased sensitivity due to dehydration. The longer the teeth are exposed to the gel and sealed away from saliva, the more a patient will experience dehydration. Dehydration can only be resolved once the trays are removed and the teeth are given time to rehydrate. Consider the recent study of overnight bleaching using Colgate’s Platinum. Over 50% of the patients tested experienced sensitivity.3 Then consider the CRA study that showed that the majority of active ingredient is spent in the first hour.4 Why continue dehydrating the teeth when most of the whitening is over?
Myth: Potassium nitrate belongs in whitening gel.
Fact: Potassium nitrate has been a successful and safe desensitizing agent in toothpaste. However, desentitizing toothpaste is used over weeks and is given time to be absorbed into the dentinal tubials. It is unclear potassium nitrate works in bleaching gel. Plus, in toothpaste, it is used on the teeth and then expect- orated, not swallowed. Patients are prone to swallowing whitening gel. It doesn’t make sense to medicate ALL patients when most won’t have sensitivity, and those who do will find better relief by using the toothpaste 2 weeks in advance of whitening treatments.
Myth: The use of Reservoirs on whitening trays.
Fact: On the surface, reservoirs seemed to make sense. Reservoirs were built into trays to increase active ingredient available for bleaching. A 1997 Haywood 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.”5 This year Reality Publishing stated, “Our own clinical study showed there were no differences in bleaching, regardless of whether a reservoir was used or not. Therefore, we no longer recommend reservoirs in bleaching trays.”6 At the same time, reservoirs are predisposed to gel leakage and swallowing and as a result can encourage gingival irritation. Reservoirs defeat van der Waal’s Force, the principal that creates a seal between the tray and the teeth; it holds the stent in place and helps resist saliva penetration and gel leakage. Additionally, some patients have a tendency to suck on the trays – reservoirs only provide more material to be swallowed.
Myth: Lasers, curing lights, plasma arc lights, or heat instruments significantly enhance tooth whitening.
Fact: Light/heat tools are precarious with limited benefit. As CRA points out, “The degree of in-office tooth whi tening depends on active ingre- dient concentration, and contact time and not application o f heat and/or light. Addition of light or heat provides positive psychological stimulus for patients and added ‘flair’ to th e procedure, but CRA data do NOT show increased liberation of active ingredient or lightening due to these stimuli.”7 CRA went on to point out that mo st laser bleaching owners studied used their system in conjunction with at-home bleaching anyway and disliked the amount of time and hands-on effort that was required.
Dr. Michael Miller of Reality stated, “Our studies, both vitro and in viv o, as well as independent studies conducted elsewhere show that there is no advantage to using any of these curing-type lights for bleaching. Heat is applied for such a short period of time, as opposed to the earlier-generation lamps that were used, that you don’t catalyze the bleach very much.” Miller also stated, “We’ve done tests in which we used light on one side of the mouth and no light on the other half and we found virtually no difference.”8 Furthermore, multiple studies warn us that the use of 35% H2O2 and heat can result in pulpal damage.9 As Dr. William Strupp explains, “Studies warn against this potentially damaging combination. I see no reason to put a patient into that kind of situation.”10
- Haywood, Van B., et al., “Tray delivery of potassium nitrate-fluoride to reduce bleaching sensitivity,” Quintessence International, Feb. 2001: 105-109.
- “A conversation with Dr. Michael Miller Part 2.” Dental Practice Report. July/August 2001: 40–44.
- Haywood, Van B., “Extended bleaching of tetracycline-stained teeth,” Cont. Esth. & Rest. Practice, Sept. 1997: 14:21.
- Clinical Research Associates, “Tooth Bleaching, State-Of-Art.” CRA Newsletter, April 1997, Vol.21: 4, p. 2.
- Haywood, Van B. Extended Bleaching.
- Miller Michael, et al., Reality 2001, Houston: Reality Publishing Co., 2001, p.1-45.
- Clinical Research Associates, “Tooth Bleaching, State-Of-Art.” CRA Newsletter, April 1997, Vol.21:4, p. 2.
- Miller, A conversation 40-44.
- Bowles WH, Thompson LR, Vital bleaching: the effect of heat and hydrogen peroxide on pulpal enzymes. J Endodon 1986;12:108-12.
- Whitener, Strupp Uses only 30%, Q3 2000 issue, pp 3-6.
CLINICIAN’S ON SENSITIVITY & 30%
Miller, Strupp, and others voice their thoughts
Do you still have questions about sensitivity using At-Home 30%? Does At-Home 30% truly belong in the mainstream of professional whitening or in the mainstream of your practice? Top clinicians have dug into the subject and have resoundingly positive answers.
Michael Miller, D.D.S., co-founder of Reality Publishing Co. and editorial board member of Practical Periodontics and Aesthetic Dentistry, had his doubts about 30% for at-home use. At a conference last winter, Dr. Miller had this to say, “When I first thought of somebody doing home bleaching with a 30% carbamide peroxide I said, ‘You’re out of your mind.’ This’ll never work, it’ll blow out teeth, they’ll be sensitive, it’ll be this, it’ll do that. Well I can tell you, it doesn’t do that. And, what’s very nice about this product is that you can have patients wear the tray twice a day for 20 minutes and you can go from a C3 to a C1 in one week ” in one week, 20 minutes a day – driving to and from work. So this 30% carbamide peroxide, as long as they keep the wear time down to a minimum and you don’t cover any of the gums, so you scallop the trays very nicely, I am firmly convinced that this is the way that home bleaching is going to go.”
Dr. Bill Strupp, D.D.S., a world-class clinician with thirty-one years of experience and the publisher of “Crown & Bridge Update” had his questions, at first. He ran his own study to compare patient experiences – one group using 15% and one using 30%. Dr. Strupp explains, “To my surprise and delight, the patients who whitened their teeth with the 30% c.p. gel were very compliant due to the immediate gratification they experienced from seeing their teeth whiten so rapidly. More importantly, the patients who chose the 30% carbamide peroxide gel did not report any incidence of acute pulpal sensitivity over my patients for whom I prescribed the 15% c.p.”
Dr. Strupp went on to say, “Some people wear any percentage 20-60 minutes, find it is too sensitive and they take it out. These are people who have open dentinal tubules, fillings that are leaking, root surfaces that are exposed, decay, or other serious problems present. You have to have a root surface exposed, or a filling exposed, or an incisal edge with the dentin showing through in order for there to be sensitivity. Just plain old virgin teeth with enamel on them typically do not get sensitive.” Dr. Strupp now whitens all of his patients with the At-Home 30%.
Robert Drosman, D.D.S., conducted a 1,400-patient clinical evaluation and statistically verified less than a 5% acute pulpal sensitivity rate. This is equivalent to only one out of 20 patients. Dr. Drosman’s 1,400 patient study has proven that at-home 30% using short-term modality is safe and effective for at-home use.
Rodney Ogrin, D.D.S., has been a pioneer of whitening for more than 11 years and is a believer in using high concentrations/low treatment times to overcome sensitivity. Dr. Ogrin was the first to introduce 15%, 20%, and 30% carbamide peroxide strengths for at-home use. He describes his experience with 30% and sensitivity, “Since the introduction of 30%, literally thousands of patients have used it to whiten their teeth without pulpal sensitivity. Soft tissue irritation is virtually a moot point when the tray is scalloped properly and when the patient follows a few simple dosage instructions.”
WHAT CAUSES SENSITIVITY?
A Reference on Causes, Symptoms, & Solutions
To best help patients have the most comfortable and effective tooth whitening experience, it is helpful to keep in mind all the different types of tooth sensitivity and their symptoms, causes, and solutions. Here is a review:
Cause: Gingival sensitivity/irritation can be caused by a tray that overlaps the gingiva, overfilling the tray, or gingival cuts or abrasions.
Symptom: Tingling, stinging gums, blanching, tenderness.
Solution: Care should be taken to trim the tray away from the soft tissue. Instruct the patient on the proper dose – a small drop in each tooth indentation for a total of only .25cc (10-12 drops in the entire tray). Less is best! Soft tissue irritation can be caused by cuts or abrasions already on the gingiva. Wounds from excessive brushing, flossing, or foods should heal before whitening.
There are three potential causes of pulpal sensitivity: exposed dentin,
dehydration, and heat.
1. Exposed Dentin
Cause: Exposed dentin is one of the main culprits of sensitivity. The dentinal tubules are able to transmit messages of cold, hot, or pressure to the pulp of the tooth. Dentin can be- come exposed for several reasons: over-aggressive brushing, receding gums, enamel erosion from acidic foods, or enamel fractures. A leaking margin is a gap between the enamel and composite material and can also cause pulpal sensitivity.
Symptom: A jolt or shock in a single tooth.
Solution: Replace or seal any leaking restorations before bleaching. Individuals with a history of sensitivity from exposed dentin should use a KNO3/Fluoride toothpaste two weeks prior to and during treatment.
Cause: Tooth dehydration occurs when bleaching trays are worn for extended periods of time.
Symptom: A dull toothache or headache.
Solution: Short-term modality allows rapid saliva re-hydration to quickly counteract the hydrostatic imbalance created by the H2O2 in the dentinal tubules and enzyme systems in the pulp. Keep treatment times short (20-30 minutes). If a patient becomes sensitive due to over wearing the trays, suspend treatment for at least 24 hours or until the sensitivity subsides.
Cause: Heat from a light source whether it be lasers, plasma arc lights, or curing lights has the potential to cause sensitivity. Post-op sensitivity has been reported by as many as 94% of patients who used a laser or light activated system.1 Pulpal damage can occur when in-office procedures combine heat and H2O2. The hydrodynamic pressures of a H2O2 exposed pulp under heat can disrupt the metabolic pathway or damage biological membrane.
Symptom: Inflammatory response that may result in pulpal necrosis and the need for future endodontic treatment.
2 Solution: Do not use a light source to whiten teeth. Heat only accelerates the whitening process by a few minutes. Not enough time is saved to warrant pulpal damage. As explained by the notable clinician Bill Strupp D.D.S., “The heat can definitely create problems. It makes no sense to me to subject a patient to that kind of risk when we can achieve such startlingly fast and predictable results with the 30% at-home whitener.” Reality’s Michael Miller, D.D.S. further explains, “Our studies, both in vitro and in vivo, as well as independent studies conducted elsewhere, show that there is no advantage to using any of these curing-type lights for bleaching.”
Another form of sensitivity not to be overlooked is TMJ.
Cause: Wearing an upper and lower stent for long periods of time can precipitate TMJ problems and tendencies.
Symptom: Jaw soreness and headache.
Solution: Use At-Home 30% as directed for 20-30 minute treatments to avoid extended wear time. If using anything else, only whiten one arch at a time.
1. Clinical Research Associates, “Tooth Bleaching, State-Of-Art.” CRA Newsletter, April 1997, Vol.21, Issue 4, p. 2.
2. Bowles WH, Thompson LR, Vital bleaching: the effect of heat and hydrogen peroxide on pulpal enzymes. Journal of Endodontics 1986;12:108-12.
Dania Dutra of Marathon, Florida used to have problems with sensitivity before she used At-Home 30%. Dania is not new to tooth whitening, having whitened her teeth for the first time in 1995.
Here is her story: “A whiter smile was not easy for me at first. I started with 10% and thought pain was just part of the whitening package. A bright smile is important to me so I do a touch up every year. I’ve tried many different products, but last year, my dentist gave me a touch up of the Life-Like At-Home 30%. Wow, what a difference! The treatments were only 30 minutes each, while in the bathroom. To my surprise, there was simply no sensitivity. Now I can keep my white smile without the pain I used to associate with tooth whitening. I love 30%!”
Helping patients prevent and manage sensitivity
Painless procedures – that’s what patients want. Giving patients what they want is returned to your practice in the form of referrals. How do you insure patients will have a painless tooth whitening experience? Reduced sensitivity and increased patient compliance can be achieved by following these guidelines:
High Concentration/Short Modality
Start with the right modality and the right product. Use At-Home 30% with 20-30 minute treatments twice a day for 7 to 10 days. The short modality helps prevent sensitivity from dehydration and allows the patient to do both arches at once without causing TMJ complications. Keeping the entire regimen from 7 to 10 days makes a huge difference in the patients’ overall comfort. As a Haywood study has shown, the first 7 to 10 days is the window for patient compliance. The right whitening prescription keeps them within this window, gives the patient the best chance of completing the treatments, and avoids requiring the patient to try again.
Careful Tray Trimming
The trays should not overlap the gingiva. Pay close attention to the trim and keep the edges smooth and off the soft tissue. When you give the patient the stent, have the patient try it on. Inspect the fit at that time to ensure there are not spots where the stent overlaps the soft tissue. For complete stent fabrication instructions with instructional photos, visit www.life-like.com/stent.
Good Patient Instruction
Stress to patients the importance of using a maximum of 1/4 cc of material. During the demonstration, make the drop into each indentation as small as possible. Show the patient the .25cc calibration marks on the syringe. “Less is best, only use small beads.” Repeat this to the patient to make sure you’ve driven the point home.
During the patient instruction give the patient these troubleshooting tips: If the gums are blanched, use less material and allow the blanching to heal 12-24 hours. If it is pulpal sensitivity, take a break for a day or two before resuming, use aspirin or ibuprofen as needed, and brush with a desensitizing toothpaste using a soft toothbrush.
SOFT TISSUE MANAGEMENT
The On and Off of Carbamide Peroxide
Did you know that tooth whitening using carbamide peroxide was originally discovered when treating soft tissue? Dentistry has learned much since those days. Carbamide peroxide is an excellent periodontal option but only when used properly. There is a time to put carbamide peroxide ON the soft tissue and a time to keep it OFF. Here are some guidelines:
Why: To treat gingivitis and periodontitis.
What: Perio-Formula 8% Carbamide Peroxide.
How: Trim the tray above the gingival line. Make sure the tray overlaps the gingiva so the carbamide peroxide is in direct contact with the gums. Only 2-3mm are needed to extend onto the gingival line.
Why: To whiten teeth fast and predictably without soft tissue irritation.
What: At-Home 30% Carbamide Peroxide.
How: Trim the tray off the gingival line and instruct the patient to avoid overfilling the tray. Pay close attention to the trim and keep the edges smooth and off the soft tissue. Overlapping the tray can cause burning, stinging, or blanching. Screen the patient. If you believe the patient cannot follow instructions, perhaps a lower concentration is a better choice. The patient needs a maximum of .25 cc of material to properly load the tray. The calibration on the side of the seal-syringe applicator is an added tool for the patient to follow dosage guidelines.
New 8% C.P. PerioFormula…
a New Ally in the Fight Against Gum Disease!
The fight against gum disease has a new ally. Life-Like Cosmetic Solutions has announced the availability of an At-Home 8% Carbamide Peroxide PerioFormula. The product gives dental professionals an effective periodontal tool that patients can use at-home. Candidates for the Perio Formula include the 80% of the adult population that has gingivitis or periodontitis. The PerioFormula’s carbamide peroxide kills anaerobic bacteria and helps remove debris between the teeth. As a bonus, use of the product helps maintain tooth whitening.
The treatment is an easy addition to dental practices and can be part of patients’ regular oral hygiene routines. It is applied using a stent that is trimmed to extend onto the gingiva by 2-3 millimeters. Only a few extra minutes are required to make an At-Home Cleaning & Debriding stent using the same stone model used for making a whitening stent. Patients wear the tray and gel for 5 to 10 minutes once a day anywhere from a few weeks to an indefinite basis, dependent on their need. Delivered in 2 oz. bottles, using the product will be routine for patients already used to whitening in a similar fashion. The use of therapeutic cleaning and debriding trays is covered by most insurances (cat.# 4381) and can be delivered by auxiliary personnel. It can be used for periodontal prevention, pre or post surgical treatment, and special non-surgical cases (geriatric cases, diabetes mellitus, and immune related disorders).
Historically, carbamide peroxide is a periodontal option that is desperately needed. 10% C.P. (Gly-Oxide and Proxigel), has been used for 50 years to treat soft tissue. Periodontal disease has been linked to heart disease, stroke, premature births, respiratory ailments, and hip replacement infections.
Call Life-Like today and ask for the “Perio-Formula Introductory Offer,” and put this new periodontal ally to work for your practice and your patients.
COMMUNITY SERVICE CORNER
In support of the disaster relief rescue workers and victims of the Washington DC, New York, and Pennsylvania terrorist attacks, Life-Like Cosmetic Solutions will be continuing the Life-Like Community Service Program.
A limited number of whitening kits will be supplied for dentists who contribute their whitening fees to relief efforts. Please fill out the community service form or request a form at 800-543-3545. Donated fees are sent to:
American Red Cross
P.O. Box 37243, Washington, DC. 20013
Designate “Disaster Relief Fund” on the memo line of the check.
The United Way of New York/The New York Community Trust
A fund established for victims and their families
Call or log on today and find out how easy it is to help America pull together.
Learn more about the Life-Like Community Service Whitening Program.
- Sensitivity Myths – Take a closer look at “zero sensitivity,” potassium nitrate, reservoirs, and overnight bleaching.
- Clinician’s on Sensitivity & 30% – Hear Miller, Strupp, and others voice their thoughts on sensitivity and At-Home 30%.
- Sensitivity Causes – Review a reference of the different types of sensitivity – the causes, symptoms, and solutions.
- Sensitivity Testimonial – Hear how At-Home 30% was the answer to a patient’s sensitivity problems.
- Sensitivity Management – The speed of short modality helps patients prevent and manage sensitivity.
- Soft Tissue Management – Review when carbamide peroxide belongs ON and when it belongs OFF soft tissue.
- New Product Announcement – Learn about a new ally in the fight against gum disease: At-Home Cleaning & Debriding PerioFormula.
- Community Service Corner – Help those in need from the attacks on America with the Life-Like Community Service Program.