By Kristine A. Hodsdon, RDH, BS
Whitening evaluations completed by hygienists will further champion the profession's ability to develop client-centered assessments and treatment planning.
Ongoing professional confusion about teeth whitening, as well as emerging clinical data and the promise of new market introductions, prompts this second part of a discussion about whitening. The focus for this month's column is power whitening, home-whitening methods, and whitening as a professional opportunity for hygienists. As a refresher, last month's column can be accessed via www.rdhmag.com.
The products in this category usually contain 30 to 35 percent hydrogen peroxide. Some manufacturers recommend activating the whitening gel with a specialized curing light. Others state that a light source is not needed for activating the gel and/or will only expose the teeth to additional heat.
While some clinical trials show that these lights may have little or no effect on efficacy, many of the power gels have proprietary ingredients. It is difficult to set up comparative studies to indicate which mode of action is superior and/or how effective a specific light spectrum is in enhancing the whitening process. With the increase in products available in this category, dental professionals should use their foundation of knowledge in separating the "glitz and promotions" from safety and efficacy data.
Some authorities suggest that the esthetic results observed in power procedures are due partly to oxidation of chromogenic material in the enamel and partly to changes in the refractive index of the enamel (caused by the high concentration of contact material). In power whitening, the results primarily may be only the rapid initial change in the enamel. This means there may not be sufficient contact time for a significant secondary oxidation of chromogenic material in dentin. Therefore, much of the esthetic effect of the power bleach may disappear as the enamel remineralizes. With this in mind, some dental professionals supplement office sessions with at-home tray whitening.
Follow each manufacturer's directions on dispensing and using power whitening products. As a word of caution, these whitening agents, due to the high concentrations, have a potential to cause significant soft-tissue irritation and/or damage. Be sure to use gingival protection. A properly placed and sealed rubber dam or a protective light-cured resin on the soft tissue provides appropriate barriers.
Many office protocols include one to three whitening sessions and 30 to 60 minutes of contact time for whitening. Remember that some manufacturers recommend agitation of the bleach while on the teeth, so a team member needs to be available. Clients should not be left alone with the gel active on their teeth.
Considerations for set-up, break-down, client education needs, and team member or doctor supervision all need to be incorporated into the total chair time and fee.
Examples of power whitening products include Opalescence Xtra, www.ultradent. com; Illumine, www.dentsply.com; Zoom, www.discusdental.com; Perfection White, www.premusa.com; and Niveous, www.shofu. com.
Home whitening methods
The home-tray method has proven to be most accessible and acceptable for the majority of our clients' needs. All of the surfaces of the teeth are treated, and it may be more advantageous to give low concentrations over a longer time period vs. intermittent high doses.
As described in last month's column, these products contain varying percentages of carbamide or hydrogen peroxide. Some other differences are viscosity, flavor, packaging, and whitening tray material. During the oxidation process, the whitening agent demineralizes enamel rods from the enamel surface right down to the dentin (some studies have found the agent in the pulp chamber). This process allows the bleach to directly contact and oxidize some of the chromogenic organic material in the underlying dentin. If a client receives clear, understandable instructions about correctly self-treating at home, the enamel channels gradually open and remain open for the weeklong or two-week regimes, allowing greater contact with, and possibly a more profound effect on, the underlying dentin. When a patient discontinues home bleaching, the more oxidized channels remineralize and close. In the client's record, remember to record the type of whitening gel used (carbamide peroxide or hydrogen peroxide), the percentage dispensed to the patient (10 percent, 16 percent or 22 percent), and the amount of gel dispensed.
If tray fabrication is accurate, the trays fit comfortably and the opportunity for desired whitening results is increased. The inclusion of reservoirs (a thin layer of block-out material placed on the facials of the teeth on the model before making the tray) continues to have its day on the debate floor. With reservoirs or without, nothing is as important as a good fitting tray.
The dental professional should assist the client as he or she practices placing gel in the whitening tray and inserting it into the mouth. Overfilling the guard could cause loss of material physically. Underfilling could cause voids that can reduce the duration of contact time between the agent and tooth structure.
Education should be both verbal and written. The client should be given a well-drafted handout that is easy to understand. Instructions may include the following contents:
- Emphasis on effectively removing plaque and bacteria from the surfaces and between teeth before inserting the whitening tray.
- The use of a whitening dentifrice before, during, and after the whitening regime is completed may help to fortify the achieved cosmetic results.
- Remove excess whitening material that may migrate on to gingival tissue after placement of the tray.
- Cease from smoking and/or drinking dark pigmented liquids during the process, and minimize the habits after completion.
- Contact the office if mild tooth sensitivity or gum irritation occurs.
- Keep the follow-up visit one to two weeks after dispensing the whitening kit so the client can share concerns and successes.
Noticeable results usually occur within one to two weeks; many patients report visible results within three days. Many manufacturers also incorporate fluoride ions and/or potassium nitrate to help minimize or eliminate sensitivity. Examples of products include Opalescence and Opalescence F/PF, www.ultradent.com; Day White 2/NiteWhite Excel, www.discusdental.com; Nupro Gold, www.dentsply.com; Zaris, www.3MESPE.com; and Life-Like Solutions, www.life-like.com.
Whitening evaluations completed by hygienists will further champion the profession's ability to develop client-centered assessments and treatment planning. Many offices have found that whitening is a gateway for many clients to move into esthetic/restorative procedures. In addition, it is vital to recognize the potential of whitening for increasing the practice's production.
On average, a hygienist may treat eight clients a day. Conservatively, if one client per day chooses whitening, then multiply the number of days of the workweek by the number of clients. Continue to multiply for weeks in a month and months per year. If one client each day chooses whitening, the math reveals that 192 clients a year choose the treatment. If the total fee for power whitening is $700, then the additional $134,400 of revenue dramatically boosts production. If the fee for home whitening is $500, then an additional $96,000 is added to the revenues.
Plug your own fees and estimates into this whitening formula to calculate your additional income potential. Guessing is great, but tracking actual dollars and case success is proof in the pudding when it comes time for performance reviews! Adding whitening options into the hygiene delivery of care is just another way to continue improving oral health, exceeding clients' expectations, and building value in the dental hygiene department.
Kristine A. Hodsdon, RDH, BS, presents seminars nationally about esthetic hygiene. She also has developed Pre-D Systems, a pre-diagnostic computerized clinical checklist for oral health professionals. She can be contacted through www.pre-d.com.