So let's play ... "Who Wants to Have Whiter, Brighter Teeth!" With the almost two-year success of the prime-time game show, Who Wants to be a Millionaire, Regis Philbin (or, for the purpose of this column, his smile) has influenced pop culture. It has spawned debates of whether or not it is "age" appropriate to bright, white, or perfect. What's your opinion?
Frankly, it really does not matter. One of the fundamental principles of esthetic dentistry is the client's perception of artistic beauty. What do patients want to achieve? As professionals, we support the process by asking facilitative questions, creating possibilities, or guiding them to clinical realities. But we should never influence our clients' wants and desires based on our personal values and judgments. Remember, it is not up to us to have their answers. We ask the appropriate questions to help them discover what they truly desire. Then we must link their desired outcomes with the finest clinical services offered by our practices.
Sometimes we find ourselves informing our clients that they have hit the "white wall." There is nowhere further to go with a type of service. If our clients desire more, then we need to re-formulate an appropriate treatment plan after a comprehensive dental hygiene pre-diagnosis and dental diagnosis.
This leads me into this month's topic - whitening. Below you will find eight statements. Some are facts, and some are fictional. I challenge you to answer the questions without moving your eyes forward to the answers and explanations. Feel free to use a "lifeline" - phone a friend or poll your team.
- Statement 1: The shade (color) of a composite resin restoration will not be affected by the whitening process.
- Statement 2: Hydrogen peroxide (HP) and carbamide peroxide (CP) whitening systems may decrease microorganisms in the oral environment.
- Statement 3: Whitening agents have been found in the pulp chamber of teeth.
- Statement 4: Minocycline, a semisynthetic of the tetracycline derivative, causes discoloration in the permanent dentition.
- Statement 5: Over-the-counter bleaching products present no risk to the client.
- Statement 6: The use of a reservoir is needed for whitening to occur.
- Statement 7: There is a point of saturation during the whitening process.
- Statement 8: The whitening time schedule for professionally dispensed, custom-fitted tray whitening is 10-14 days.
Is Regis smiling?
Here's a discussion of the questions above. How did you do? Still have any lifelines left? Is Regis rolling his eyes?
Statement 1 is fictional. Practitioners have been aware that whitening teeth with tooth-colored restorations can create a difference of a shade between the new tooth color and the original restoration. The common thought is that the teeth change color while the restoration does not. Some studies are concluding that color changes do occur in tooth-colored restorations. Arguably, more research is needed before we are able to accurately determine to what degree the restoration will change color. But we should discuss this possible result with our clients prior to beginning whitening procedures.
Statement 2 is factual. Historically, HP solutions have been used to treat gingival inflammation. HP and CP are also documented as effective antimicrobial agents. One study by Dr. Carolyn Bentley concluded that a medium viscosity 10 percent CP solution used in a fitted tray for only one hour per day for six weeks reduces lactobacilli (caries-producing bacteria) salivary levels. So some of the secondary benefits of whitening - at least during the whitening process and shortly afterward - may support a caries-control prevention plan.
Statement 3 is factual. A small number of in vitro studies have concluded that whitening agents do chemically diffuse into the pulp chamber of natural and restored teeth. The penetration into the pulp varies, depending on the whitening gels used and the status of the pulpal chamber. In addition, the diffusion varies depending on restorative materials. Composite resin material, for example, show the least pulpal penetration. This information should be considered when developing whitening programs and during explanations to clients.
Statement 4 is factual. We are familiar with information about how tetracycline causes discoloration of developing teeth in children. However, minocycline (sometimes prescribed for the treatment of acne and rheumatoid arthritis) also has the potential of causing pigmentations of teeth in the permanent dentition. Scientific literature is not conclusive about the why, how, or when during the antibiotic treatment cycle this occurs. But the evidence does suggest that a corresponding protocol of vitamin C may help prevent the discoloration.
Statement 5 is fictional. Recent introductions into the over-the-counter (OTC) bleaching market need more clinical testing to determine their effect on our clients. We are aware of some clinical problems with bonding teeth too soon after bleaching, excessive bleaching that may lead to enamel fractures, dehydration of the tooth structure, and penetration into the pulp chamber. Preliminary data does show newer OTC strips to be effective; however, haphazard use or overuse of these products is a concern. How will consumers diagnose whether they are appropriate candidates, or will they react to sensitivity appropriately? Will they be timely in relieving their OTC bleaching protocol (type and frequency), so it does not negatively affect any restorative services? How will they know when to stop bleaching?
Statement 6 is fictional. Creating the whitening reservoir involves light-curing composite spacers on the client's model prior to tray fabrication. These areas provide additional space between the tray and the teeth being treated. A few studies have concluded that reservoirs are not needed for whitening to occur, may not affect the clinical rate that whitening occurs, or the efficacy of the whitening gel. With various manufacturers tooting their claims of superiority over competition, keep this emerging and time-saving information in mind.
Statement 7 is factual. Natural teeth will only lighten to a certain point/shade. It is part of the pre-diagnosis to record the shade prior to beginning. During all of follow-up sessions during the prescribed regimen, the shade should be documented. This will aid the final decision to stop treatment. When the teeth do not get lighter, the process should then stop. About three to seven days afterwards, the client should return for assessment, a recording of the final shade, and move onwards into the whitening management phase. If the client's perception of optimal whitening has not occurred, further discussions of appropriate clinical services can be discussed. If the client is happy, the shade of the teeth should then be recorded at the beginning of every hygiene or restorative session. This will continue to add value to the original whitening process and alert the professional and client if any color relapse has occurred. This monitoring will support timely and controlled "touchups." Remember, overdoing the whitening treatment will not induce further lightening, but it may lead to increased sensitivity, dehydration of the tooth structure, and reduction in the enamel toughness against fracture.
Statement 8 is fictional. Even though this statement can be misleading, it challenges the misconception that all teeth are created equal and all clients should have the same whitening schedule. In 1989, Drs. Haywood and Heymann prescribed expected whitening protocols of two to six weeks. Somehow, the profession has confined itself to the thought that all at-home whitening should take only 10 to 14 days. Some treatment times have been reported to be as long as two months to a year, particularly cases involving tetracycline-stained teeth. The solution is customizing whitening modalities for patients.
References available upon request.
Discussions about the link between periodontal disease and other medical conditions are becoming pretty commonplace. Here's another link: www.rdh.net. In the July 2000 issue, Trisha O'Hehir offered an update on the connection between perio and preterm babies, heart disease, lung disease, diabetes, and peptic ulcers. To review the column, access rdh.net and search for "O'Hehir." The column referred to above is in the list. But since her other columns are there too, feel free to catch up on your reading.
Kristine A. Hodsdon, RDH, BS, presents seminars nationally about esthetic hygiene. She also has developed Pre-D Systems, a pre-diagnostic esthetic enrollment software for oral health professionals. She can be e-mailed at www.pre-d.com.