Patient Teaching: Tooth Whitening
Everybody loves a bright white smile, and there are a variety of products and procedures available to help you improve the look of yours. Many people are satisfied with the sparkle they get from brushing twice daily with a fluoride-containing toothpaste, cleaning between their teeth once a day and the regular cleanings at your dentist's office. If you decide you would like to go beyond this to make your smile look brighter, you should investigate all of your options.
You can take several approaches to whiten your smile:
| In-office bleaching |
| At-home bleaching |
| Whitening toothpastes |
Talk to Your Dentist
You may want to start by speaking with your dentist. He or she can tell you whether whitening procedures would be effective for you. Whiteners may not correct all types of discoloration. For example, yellowish-hued teeth will probably bleach well, brownish-colored teeth may bleach less well, and grayish-hued teeth may not bleach well at all. Likewise, bleaching may not enhance your smile if you have had bonding or tooth-colored fillings placed in your front teeth. The whitener will not effect the color of these materials, and they will stand out in your newly whitened smile. In these cases, you may want to investigate other options, like porcelain veneers or dental bonding.
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You also may want to speak with your dentist should any side effects become bothersome. For example, teeth can become sensitive during the period when you are using the bleaching solution. In many cases, this sensitivity is temporary and should lessen once the treatment is finished. Some people also experience soft tissue irritation—either from a tray that doesn't fit properly or from solution that may come in contact with the tissues. If you have concerns about such side effects, you may want to discuss them with your dentist.
Dental Office Bleaching
There are two effective bleaching methods commonly used by dentists in the dental office–the in-office "power" bleaching and laser bleaching.
The in-office "power" bleaching is one of the quickest and most effective ways to whiten teeth but requires a session at the dentist's office. The dentist isolates and protects your lips, gums, and inside lining of your mouth. Next, a powerful bleaching agent is applied to the teeth. Finally, a powerful light source is applied which completes the procedure by activating the bleaching agent.
While this provides one of the best results of any bleaching methods, it is
moderately expensive, ranging from $300-$600 per arch or $600-$1200 for all of your teeth. (In
dental terms an arch is either the upper set or lower set of teeth).
Laser Bleaching
Laser bleaching is a relatively new procedure only recently receiving FDA approval. Despite its high tech sounding name, laser bleaching is simply a variation of the above in-office power bleaching method.
The procedure is much the same. Gums and lips are protected and a
bleaching agent is applied. The only difference is that an argon laser is used to activate the
bleaching agent instead of the usual light source.
Inventors of the procedure claim that this
produces a better whitening result than the conventional in-office power bleaching. We must say that
the jury is still out. This is a case where clinical studies need to be performed to substantiate
these claims. Laser bleaching does cost more than the typical in-office power bleaching, ranging
between $750 to $2000 for a complete set of teeth.
Basics of the In-Office Bleaching
There are a number of bleaching procedures that your dentist can perform in the dental office:
| For your upper arch only, the dentist can make a custom mouth piece, use a relatively high concentration of bleaching material (often called Power Bleach), and have you wear it in the office. |
| A single tooth or set of teeth can be bleached using very high concentrations of the bleaching material. Your soft tissue is protected during these procedures. |
| This procedure, combined with take-home dentist-dispensed bleaching is effective in the treatment of severe staining due to trauma and exposure to certain drugs such as tetracycline. |
| The inside of a tooth can be bleached after a root canal procedure to lighten it to match the surrounding teeth. |
Pros. Fast dramatic results can be achieved. You can have immediate results for a special event. Specific problem teeth can be lightened to match the rest of your smile. You are working with a professional who knows how to handle such ingredients and procedures and can integrate bleaching into your overall oral health care plan.
Cons. The cost is higher than over-the-counter products. Minor and transient tooth sensitivity can occur for some patients.
ADA News Release
A report by Dr. David Garber, a private care dentist and a clinical professor at the Medical College of Georgia School of Dentistry, suggests that combining in-office power bleaching with dentist-dispensed at home whitening trays may provide both immediate tooth shade lightening and longer-lasting effects. He also points out that the new cosmetic laser bleaching may provide a quick and longer-lasting solution for some.
The combination of power bleaching and dentist-dispensed bleaching is accomplished by treating the teeth for 30 minutes with a concentrated formula of hydrogen peroxide and then providing two weeks of treatment for 30 minutes each day at home. In-office power bleaching is characterized by rapid lightening using a high concentration of hydrogen peroxide (usually 30-35 percent) that is activated by heat and light. Patients wear a rubber dam to protect their soft tissues from the high concentration of hydrogen peroxide.
"While in-office power bleaching alone can be quick and dramatic, the patient often must come back for multiple treatments because the original stains or shade may return," said Dr. Garber. The combination of power bleaching with a 30-minute per day, every-other-day at-home bleaching schedule can achieve the most rapid and predictable results, he contends.
New laser bleaching may also be an option for some patients who want dramatic whitening effects quickly, Dr. Garber reports. Recently approved by the Food and Drug Administration for marketing as a light source, lasers have garnered a great deal of attention in the consumer press. The ADA's Council on Scientific Affairs at its January 2000 meeting issued a call to manufacturers for clinical data proving that laser bleaching is safe and effective.
Dr. Garber points out that lasers used for lightening teeth do not bleach teeth, they merely create a reaction when the hydrogen peroxide comes in contact with the laser's beam. It is this reaction that begins to lighten teeth.
"At this stage, there is little research that proves that any of these approaches are more effective than traditional bleaching methods," he reports.
Dr. Garber presented his findings at "The International Symposium on the Non-Restorative Treatment of Discolored Teeth," held last fall at the School of Dentistry of the University of North Carolina at Chapel Hill and supported by Colgate Oral Pharmaceuticals.
Source: The Journal of the American Dental Association (JADA).
These systems are becoming increasingly popular. With these systems the dentist makes a mold of your teeth. This mold is then used to create custom mouthpiece trays which snugly fit your teeth.
The patient takes the trays and bleaching agent home. Each night for three to four weeks the patient places bleaching agent on the trays and places the trays in his or her mouth. A brief visit or two to the dentist ensures that you are doing the home treatments correctly and allows the dentist to inspect your gums for irritation.
What we like about these systems is that the mouthpiece trays are custom made to fit each individual's mouth. This means that bleaching agent is less likely to be swallowed or less likely to seep onto and irritate gum tissue.
Second, when using these systems the patient visits the dentist office to ensure that the procedure is proceeding smoothly. This allows the dentist to make sure the custom trays are fitting properly. More importantly, it allows the dentist to check for gum irritation / damage and allows the dentist to check for tooth sensitivity. These are the most common side effects of the bleaching procedure.
These systems can cost between $250-$300 per arch ($500-$600 for all of your teeth).
For extremely yellow teeth, an in-office power bleaching is performed followed by treatment with a dentist-supervised take home system. This usually provides good results.
Over-the-counter (OTC) bleaching systems are take home kits which you can buy at the local store, order by mail-order, or buy off the Internet. Usually they are relatively inexpensive costing from $29 - $175.
These kits work in a similar fashion to the dentist-supervised take home kits. A bleaching agent is applied to a mouth tray and the tray is inserted into the mouth for 2-8 hours. Treatment lasts between 2-4 weeks. We personally do not recommend these kits for two reasons:
First, many of these kits contain a standard mouthpiece tray for applying bleach onto your teeth. Because the trays are standard (made to fit everyone), they tend not to fit snugly. Consequently, you may be ingesting bleaching agent. In addition, trays which are not custom made allow bleach to seep onto and irritate gum tissue.
Second, dentists do not check your teeth and gums when you use these systems to determine if the bleaching process is proceeding safely and to ensure that you are not injuring your teeth.
While we do not recommend these systems, if you do want to take the risk and use them, we would recommend that you do the following when evaluating the wide array of take home systems available:
| If possible try to use a kit that allows you to customize your mouth trays to some degree. Some systems come with moldable mouth trays which better fit your mouth. While not as good as the mouth trays created by your dentist, they are better than standard mouth trays that come with many kits. Try to find others who have used the system you plan to use and ask them how the system worked for them. While some people have been satisfied with results, others have had horrible experiences. While using the system, if you ever experience prolonged pain, changes in gum tissue color, or increased sensitivity to hot or cold foods, see a dentist immediately. |
Whitening Toothpastes
A common trend has been the proliferation of toothpastes which claim to whiten teeth. Sometimes these claims mistakenly lead consumers to think that these whitening toothpastes are miracle cures.
These toothpastes are not effective at whitening the underlying tooth. What they tend to do is remove stains so that the underlying whiteness of the tooth becomes more apparent.Think of these toothpastes as "carwashes" for your teeth. In the same way that a good car washing removes the dirt and grime on your car making it sparkle, whitening toothpastes remove stains and crud from your teeth. Smokers toothpastes work in much the same way removing tobacco-associated stains from teeth.>Be aware that there is great variability in the effectiveness of these toothpastes. Some may work extremely well while others may only make teeth appear whiter by one shade or less. To obtain a more dramatic improvement, other techniques such as bleaching are often tried.
It is important to note that while effective in removing stains, many brands of whitening and smokers toothpastes can destroy tooth enamel in the process. These toothpastes use harsh abrasives to remove the stains. Over long periods of repeated use, these harsh abrasives begin to remove tooth enamel making teeth appear yellow and causing teeth to become sensitive to cold or heat.
We suggest using one of the newer breeds of whitening toothpastes which do not contain harsh abrasives but instead use other methods for removing stains from teeth.
Source: Dental Zone
www.saveyoursmile.com
Porcelain Veneers Porcelain veneers are a popular option. These are very thin pieces of porcelain which are shaped and placed on the front of the tooth with a resin glue (analogous to placing paneling on a wall).
The advantages of veneers are that they provide for a brilliantly white smile which is resistant to discoloration and fades only very slowly over time. These veneers can be expensive, however, costing around $250 per tooth veneered.
Bonding
Caps
Caps represent a more drastic measure and are usually reserved for teeth completely broken down, teeth with fillings, or teeth having undergone a root canal. The tooth is totally ground down, an impression made, and a porcelain-metal cap added to the tooth. The cost - nearly $1500-$1800 per tooth.
Special Situations
Some people have discolored teeth as a result of their mothers having been treated with
tetracycline during pregnancy or as a result of having themselves been treated with tetracycline
during early childhood. These stains can be especially difficult to remove.
| Bleaching Method | Dentist-in- office power bleaching | Laser Bleaching | Take home dentist-supervised bleaching | Over-the-counter bleaching system |
| Type of System | Traditional thermocatalytic. Active ingredient:30-35% H2O2. | Same as in-office treatment | 10% carbamide peroxide with bleaching
tray. 3% H2O2.
|
Over-the-counter 3-step bleaching system . 6% H2O2. |
| Procedure | Dentist isolates and protects lips, gums, and inside of mouth. A bleaching agent is applied to the teeth. Finally, a powerful light source is applied which completes the procedure by activating the bleaching agent. | Similar to in- office power bleaching with the exception that a laser is used as the light source which activates the bleaching agent. | Dentist makes custom mouthpiece trays which snugly fit your teeth. Each night the patient places bleaching agent on the trays and places the trays in his / her mouth. | Patient places bleaching agent on mouth
trays that come with kit. Tray is placed on teeth overnight.
|
| Time | 1-2 hours | 1-2 hours | 2-3 weeks | 2-3 weeks |
| Cost (per whole set of teeth) | $600-$1200 | $750 to $2000 | $300 to $500 | $40 to 300 |
| Advantages | Produces best results. Quick and convenient. | Proponents say produces better results
than dentist-in-office bleaching. Jury still out. Nevertheless produces excellent results. Quick and convenient. |
Produces good results. Dental follow-ups during treatment make sure things are proceeding well with no adverse side effects. | Inexpensive. |
| Disadvantages | Relatively expensive. | Relatively expensive. | Requires sticking gel and tooth tray into your mouth for two to three weeks. | Not recommended. Very poor results. Standard fit mouth tray can cause bleaching agent to seep onto and damage gums. No dental follow-ups to ensure that procedure is proceeding without side-effects. Requires sticking gel and tooth tray into your mouth for two to three weeks. |
Questions about the safety and efficacy of this bleaching technique have been raised by patients, dentists and recently by U.S. Food and Drug Administration. Past surveys have provided some answers to these questions.
In one such survey, 90% of the dentists who used this type of home bleaching method thought that patients were satisfied with the technique; 66% reported side effects such as gingival irritation (28%) and tooth sensitivity (23%). In another clinical trial, patients using 10% carbamide bleaching solution were pitted against patients using a placebo. A significant difference in color change was found in patients using the carbamide peroxide solution. Another study reported successful color change after 5 night-time applications of the carbamide peroxide, but there was an initial color reversion. However, the reversed color was still significantly lighter than the initial color and remained lighter 3 months after treatment. The lasting effect of teeth bleaching, however, has not been confirmed by any documented studies, but it is generally estimated to last 1-3 years.
The instant clinical trial by Hayward, Leonard et al. described below was undertaken with four objectives:
| to determine the effectiveness of a nightguard vital bleaching technique in a controlled population of patients over an extended period; to document any side effects of treatment with two different 10 percent carbamide peroxide solutions on gingival tissue and teeth during treatment; to evaluate the stability of the bleaching treatment over time; to determine if any side effects continued or surfaced after treatment stopped. |
Thirty-eight adult patients who had expressed concern about their discolored teeth were selected for this clinical trial. These patients were divided into various categories based upon causes of staining, such as tetracycline, aging or inherent discoloration, brown fluorosis and trauma.
The patients were given a six-week supply of one of two 10% carbamide peroxide solutions (Proxigel, Reed & Carnrick or Gly-Oxide, Marion-Merrell Dow Lab, Inc.) Patients were instructed to wear the nightguard for six to eight hours at night, or to wear the guard during the day and change the solution every two to six hours.
The success of the trial including the change in color and the lasting change in color were measured by the patient's perceptions of the color of their own teeth as compared to the untreated lower arch or a standardized color shade tab. The ultimate goal of any teeth bleaching treatment is patient satisfaction which in turn is the result of patient's perception of the status of their teeth.
Conclusions
Carbamide peroxide in a 10 percent solution effectively lightened the color of teeth in 92 percent of 38 patients in a six-week period, with an average daily wearing time of seven to eight hours. Teeth stained by aging, brown fluorosis, trauma or inherent discoloration were lightened in 96.7 percent of the patients, and tetracycline-stained teeth were lightened in 75 percent of patients. Teeth stained by tetracycline did not lighten as much as teeth stained by other means.
A significant number of patients, about 66 percent, experienced transient side effects of gingival irritation and/or tooth sensitivity during treatment. However, these side effects did not prohibit continuation of treatment, and generally lasted four to seven days. The two major side effects reported were tooth sensitivity and gingival irritation. The sensitivity of the teeth may be caused by the easy passage of the hydrogen peroxide and urea through the teeth to the pulp, resulting in a reversible pulpits.
Furthermore, the sensitivity of the gingival could have been caused either by mechanical irritation from the nightguard or chemical irritation of the solution. With adjustment of the guard, cessation of treatment, and/or decreasing the treatment time for several days, the gingival irritation resolved. No side effects occurred or returned at 13 to 25 months after bleaching.
Seventy-four percent of the group noted no noticeable decrease in the color of their teeth after 13 to 25 months with no further treatment. None of the bleached teeth that had received no further treatment had returned to the original color. Patients who had retreated their teeth did so after at least one year, and retreatment required a much shorter time than the original bleaching treatment. Three years after treatment (31 to 42 months), 62 percent of the respondents had no perceivable loss of color lightening, and no side effects had occurred.
Source: Haywood VB, Leonard RH, Nelson CF, Brunson WD: Effectiveness, side effects and long-term status of nighguard vital bleaching. J Am Dent Assoc 125: 1219-1226, 1994.
Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989;20:173-176.
Haywood VB, Leech T, Heymann HO, et al. Nightguard vital bleaching: Effects on enamel surface texture and diffusion. Quintessence Int 1990; 21: 801-806.
Haywood VB, Heymann HO. Nightguard vital bleaching: How safe is it? Quintessence Int 1991; 22:515-523.
Albers HF. Home bleaching. ADEPT Report 1991; 2(1): 9-17.
Haywood VB. History, safety, and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. Quintessence Int 1992;23:471-488.
Croll TA: Tooth bleaching for children and teens: a protocol and examples. Quintessence Int 25:811- 817, 1994
Haywood VB, Leonard RH, Nelson CF, Brunson WD: Effectiveness, side effects and long-term status of nighguard vital bleaching. J Am Dent Assoc 125: 1219-1226, 1994
Goldstein GR, Kiremikjian-Schumacher L. Kriser Dental Ctr, 345 E 24th St., New York, NY 10010. Bleaching: Is it safe and effective? J Prosthen Dent 69(3): 325-8, 1993
Studies by Tooth Bleaching System Manufacturers
The efficacy of tooth bleachers was also studied by dental product manufacturers. They concluded that their products were effective in achieving lightening effects (1,4,5,6,9). Lightening effects were variable from individual to individual and also according to which system was used. Patient satisfaction was highest in dentist-prescribed at home systems (5,6,8). Treatment time is about five to six weeks for the prescribed in home systems.
The same results can be achieved in less time by using the in-office procedure. It must be noted that this search yielded no evidence proving the efficacy of over-the-counter type systems. They were branded as unsafe and ineffective due to their lack of studies backing up their claims. Another question that is closely related to efficacy is longevity of the achieved results. Generally, noticeable cosmetic results can be achieved but how long do they last? For both in-office and dentist-prescribed, retreatment was necessary every one to three years to maintain the initial results (2,4).
The issue of product safety is still in question by the ADA and to date, no product currently available to the public is ADA approved due to lack of substantial evidence proving their safety. But product manufacturers of bleaching products have conducted their own studies proving their safety. They cite evidence disputing bleaching agent's active ingredient( hydrogen peroxide), carcinogenic potential (1,4,8). They claim the concentrations of hydrogen peroxide in their products do no harm to gingival tissues, pulp, enamel, and restorations. Upon conducting their studies, product manufacturer's data concluded that the only side effects were unpleasant taste, slight tooth sensitivity, and minor gingival irritation. All these symptoms were reversed upon the cessation of treatment (3,4,9). (These were studies done for dentist-prescribed in-home systems).
For products used in in-office systems, the higher concentration of hydrogen peroxide caused reversible plural damage which resulted in post treatment sensitivity (7). Again, over-the-counter systems were noted as being unsafe because of their acidic and abrasive ingredients. It was also pointed out that due to lack of dental supervision and evaluation, dissolution of tooth enamel could occur if used improperly(4). Also, their potential to become abused in haste to achieve a lightening effects was noted, and use of these kinds of products can be of more harm than good.
Discussion
As the literature review progressed, it became evident that the safest and most effective methods were those conducted under dental supervision. Evaluation by a dentist is important in determining if bleaching will be effective. In contrast, OTC systems place the consumer in the role of deciding what is best for the treatment without having any real background knowledge of the subject and its potential harmful side effects. Using a dentist-prescribed system ensures that proper care and maintenance will be given to the patient. Use of OTC does not give this assurance. Often, these systems are abused due to consumer ignorance or impatience to reach desired results. It is important that people considering tooth bleaching get evaluated and educated by a dentist as to the possible achievable results as well as to possible adverse effect of bleaching products. It would be time well spent in asking the dentist questions and receiving background information than to hastily purchase a glamorous gimmick that has not been proven to be safe and effective.
Conclusions
| Dentist supervised systems have been proven safe and effective.
| The safety and effectiveness of OTC bleachers are undetermined.
| There are some adverse side effects associated with each system.
| Patient satisfaction is highest for dentist-prescribed in home systems.
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Source: Chin Edward A, Franssen Susan, Dwan Andrew, Hufunda Joe, University of Michigan School of Dentistry.
Berry JH. What about whitener? Safety concerns explored. J Am Dent Assoc 1990 Aug;121:222-5.
Goldstein GR, Kiremidjian-Schumacher L. Bleaching: is it safe and effective? J Prosthet Dent 1993 Mar;69:325-8.
Haywood VB. History, safety, and effectiveness of current bleaching techniques and applications of nightguard vital bleaching technique. Quintessence Int 1992 Jul;23:471-88.
Howard WR. Patient-applied tooth whiteners. J Am Dent Assoc 1992 Feb;123:57-60.
Ibsen R, Ouellet D. Rembrandt Whitening System and Quick Start versatile tooth bleaching systems. J Esthet Dent 1991 Sep-Oct;3:169-73.
Reinhardt JW, Eivins SE, Swift EJ Jr, Denehy GE. A clinical study of nightguard vital bleaching. Quin tessence Int 1993 Jun;24:379-84.
Shearer, AC. External bleaching of teeth. Dent Update 1991 Sep;18:289-91.
Simon JF, Allen H, Woodson RG, Eilgers AS. Efficacy of vital home bleaching J Cal Dent Assoc 1993 Jan;21:72-5.
Tam L. Vital tooth bleaching: review and current status. J Can Dent Assoc 1992 Aug;58:654-60.