A Masterpiece in the Making

Jan. 1, 2005
The creation of a white smile leads to a difference of opinion that can be as confusing as, well, a box of crayons.

The creation of a white smile leads to a difference of opinion that can be as confusing as, well, a box of crayons.

A crayon box contains a wide array of colors. As children, basic colors like red, green, purple, and orange were often used when creating a work of art. Primary colors such as yellow were always named yellow; blue was blue; and white was just named white. Now, fingering through the crayons is a confusing experience because the names have been altered. Red is no longer just red but orange-red or radical red and yellow is now mellow yellow or lemon yellow. How does one explain to a child learning basic colors that this crayon is green when the wrapper reads spring green or asparagus green?

We tend to attach certain colors to certain objects. Foodstuffs are a hot topic for naming crayons. Once the top of the box is flipped open, one will find carrot, melon, lime, cocoa, olive, and even a cheesy macaroni. When we created our masterpieces as kids, few of us chose black or yellow to color the smiling teeth on the characters in our coloring books (unless it was a scary face). Usually, we chose white. Perhaps this is a reason many adults now cling to youthful thoughts of pure white teeth and long to remove the yellow through modern whitening methods.

Crayons have a century-long history and have remained an arts-and-crafts mainstay. Hundreds of different color variations have been added to the basic boxed assortment to complete the palette. Interestingly enough, with so many color varieties and names, the hue of white has always remained “white.” So, when our patients state, “I would like white teeth,” we can visualize the hue they desire by merely picturing a white crayon.

Chairside, we grab a standard shade guide, choose which “yellow” tab matches their teeth at present, and show the patient a couple of tooth tabs lighter to demonstrate how their teeth can reach a whiter shade. As our patients try different whitening systems (both professional and over-the-counter), the standby B1 tab found on a basic VITA shade guide no longer applies as the whitest attainable shade. For years, patients have strived to be a B1, and some have tipped the guide and gone lighter. In response to a need to label those shades, a new shade guide has been developed for those “whiter than white” smiles. The bleached tab, “0” (zero) group guide was created by VITA. Tabs are letter labeled and closely resemble the white crayon.

Clinicians may also accurately measure the patient’s prewhitened smile by using a high-tech hand-held VITA Easyshade unit placed directly on the tooth surface. A precise shade measurement is assigned and viewed in the window of the compact unit.

Whitening products and systems need to have an accurate baseline shade for the teeth in order to gauge a successful result. As hygienists, we have suggested numerous whitening systems with incredible claims of lightening several shades. For this reason, taking preliminary (prewhitening) intra- and extraoral images of the unbleached smile remains invaluable.

Also, observe the patient’s sclera (opaque eye tissue commonly known as the “whites of the eyes”), because, as we age, the sclera tends to become more yellow. Compare the whites of the eyes to the shade of the teeth. When the teeth appear many shades darker, whitening the teeth will balance the overall look of the face. (After all, the glamour magazines airbrush the whites of the eyes and teeth for balance.) With the lightening of teeth, we can help reverse years of intrinsic staining and make patients look younger.

On occasion, patients’ expectations were so high that, no matter how the whitening system performed, it did not perform as successfully as they had desired. They turn their head in disappointment to the hygienist and whisper, “My teeth did not change at all.” Drawing on the pretreatment images, we validate for the patient the degree of change that was attained by the chosen system. Also, taking the shade guide in hand, we show the patient the starting tab we recorded as the value of lightness and the hue (degree of yellow cast from the tooth we chose) assigned to the prewhitened teeth. When patients see for themselves that change has indeed occurred, they are generally reassured and pleased. To further document the successes, take before and after photos of the patient.

Changing colors

An added benefit to whitening patients’ teeth is improved home care. Our home-care advice to them becomes an invaluable maintenance step. For some patients, the sensitivity issue plays an annoying part of their lightening experience. Porous tooth structure, exacerbated by cool beverages and food, cries out for remineralization. Depending on the degree of sensitivity experienced, different recommendations may be made. Sensitivity toothpastes solve many of the long-term issues our patients have dealt with daily. The continual use of these desensitizing pastes layers microscopic barriers of protection against harsh oral temperature changes.

Some professional whitening products, delivered in syringe systems, are designed to reduce sensitivity by adding fluoride ion directly to the whitening products during the application. Look for products that incorporate sensitivity protection for any discomfort after whitening. Many manufacturers offer whitening products in varying levels of active ingredients. If a patient experiences unwanted sensitivity with an 18 percent peroxide bleach formula, perhaps a 10 percent syringe can be tolerated. Also, whitening products are worn or used for a different amount of time, and every product performs best when the directions are stringently followed. Whitening strips, placed on the tooth surface, can be worn anywhere from seven days, three weeks, or overnight.

Patients who long for white teeth want to experience the least amount of sensitivity and receive the best whitening results possible. Each patient must be individually assessed, and treatment plans need to reflect the patient’s wishes. Some patients will not be hindered by cost and will want to undergo in-office (controlled) lightening procedures, possibly enhanced by a laser. Others want to start more conservatively and will try a box of the strips, a paint-on product, or a wand they saw advertised.

Patients who have undergone a dramatic smile change through whitening are receptive to home-care recommendations. Embrasure spaces and cervical lingual margins are difficult areas for patients to actively remove stains, so patients seek the professional advice we gladly share. After all, when teeth are lightened, the accumulations of stains are highly contrasted (black on white) and are very visible to the eye. Interproximal devices, both manual and mechanical, remove the plaque that stains the teeth so easily. White teeth are not so nice when covered with a thick layer of yellow biofilm.

When patients state they want a white smile, they are merely saying, “Get all the dark colors out of my teeth.” Return to the youthful days of crayon-white teeth by utilizing modern whitening systems and helpful maintenance products.

Karen Kaiser, RDH, graduated from St. Louis’ Forest Park dental hygiene program in 1994 and currently practices at the Center for Contemporary Dentistry in Columbia, Ill. She has written several articles for RDH and other publications, sits on dental hygiene panels, and is an evaluator for Clinical Research Associates. She can be contacted at [email protected].

Minimizing sensitivity

One recent study focused on patients who used a desensitizing toothpaste that contained 5 percent potassium nitrate with fluoride (Sensodyne). The subjects used the toothpase two weeks before and during professional whitening treatment. The treatment involved a product containing 9.5 percent hydrogen peroxide with potassium nitrate. The patients experienced significantly less sensitivity compared with a control group using a regular toothpaste, and the desensitizing toothpaste did not interfere with the results of the whitening procedures.

Along with a desensitizing toothpaste, recommend a soothing rinse of dispensed fluoride to alleviate general sensitivity as well as seal the tubules, possibly allowing less extrinsic stain to deposit on the whitened surface. Another product to combat whitening sensitivity is PROSPEC MI Paste (GC America). This paste contains Recaldent®, which delivers bio-available calcium and phosphate to tooth surfaces. PROSPEC MI Paste is placed directly by finger to sensitive tooth structure and can be ingested. Patients with milk protein allergies should avoid using this product. Striking the right balance for whiter teeth with less sensitivity, plus finding an effective maintenance product, remains the challenge.

Whitening toothpastes contain abrasives to remove the unsightly yellowing buildup caused by food and beverages. Abrasive combinations can cause tooth sensitivity by stripping the natural protective layers. Thankfully, lower abrasive reformulations for whitening pastes have emerged and can be used daily. Discovering which combinations and brands suit our patients can be a trial and eliminating process until the product produces the desired result. Other maintenance products may include whitening chewing gums or mouthrinses and can be used in conjunction with pastes.