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Magnificent obsession

Sept. 1, 2006
When tooth whitening becomes an addiction
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When tooth whitening becomes an addiction

Tooth whitening has become a common, widely accepted, desired, and often-requested dental procedure for patients of all ages.1 The effectiveness and safety of whitening products are well documented, and many over-the-counter (OTC) products carry the ADA seal of approval. Our clients are inundated with whitening products in stores, from toothpastes and mouthrinses to paint-on and strip-type whiteners. Advertisers go to great lengths to promote these products, which project the illusion of beauty, confidence, and success through whiter teeth and a bright smile. The patient’s perception of attractiveness and desire for these products has followed.2,3 A study by Procter & Gamble revealed that more than 90 percent of people surveyed considered white teeth as a sign of good health and attractiveness.4

Creating desire for a product is not new, and manufacturers of toothpastes and other products have been doing it for generations. Toothpastes do little harm to patients who overuse them by brushing many times a day. But overuse of tooth whiteners is an entirely different story. As providers of health care and experts in our field we must ask, when does that innocent desire become obsessive and destructive? When must we intervene on behalf of our patients’ well-being?

In an interview on “Good Morning America,” self-described tooth-whitening junkie Jessica N. admitted she abuses whitening products, and uses them far beyond product recommendations with applications up to twice a day for months at a time.

“Whatever the cost, whatever the pain, whatever it takes to get there, I’ll do it,” she said.5

Unfortunately, Jessica is not alone.

Dubbed “bleachorexics” by cosmetic dentist Dr. Nancy Rosen and others,4,6 a growing number of people driven to achieve the perfect shade of white become obsessed with whitening products and use them to dangerous levels. Like the anorexic who sees herself as overweight, the bleachorexic is never satisfied with the whitening level. This overuse leads to inflammation, recession, sensitivity, and translucent teeth, the natural shade gone forever.4-7 How did we get here?

The dental community has historically taken a conservative approach to treatment, with hygienists as champions of oral health and self-care. We have worked hard to engage patients to take an interest in their oral health care. Now we find ever-increasing numbers of people who are obsessed with whitening and the appearance of their teeth. Where are they obtaining the products and how safe are they?

Carbamide peroxide, the active ingredient in tooth whiteners, can be found in strengths as low as 10 percent in OTC products to as high as 35 percent in dental office products. It functions by breaking down from a water-based solution into hydrogen peroxide and urea, with hydrogen peroxide being the active bleaching agent.8 This releases a highly reactive form of oxygen, which penetrates the tooth enamel and lightens the tooth shade.9 The factors that directly influence the whitening process are the concentration of carbamide peroxide and the length of time teeth are exposed to the product.10 When used according to product recommendations, whiteners are safe and effective with few ill effects.

For the last 10 years, the ADA Council of Scientific Affairs has monitored the development and increasing numbers of whitening products on the market. OTC whiteners that bear the ADA Seal of Acceptance contain no more than 10 percent carbamide peroxide, and clinical data on neutral pH 10 percent carbamide peroxide continue to support both the safety and effectiveness of these agents. Professionally applied whiteners carrying the same seal contain 35 percent carbamide peroxide.8

When used as directed, the most common side effects are transient tooth sensitivity and gingival irritation from contact with the whitening product.11,12 These undesirable effects normally subside in a short period of time with little or no intervention other than removing the irritant. If the patient experiences undue sensitivity, desensitizers and topical fluorides can be easily applied. But these are not the only available products, and patients determined to achieve that “whitest smile” will not only seek out higher concentration products, but will use them outside prescribed guidelines. This leads to obsessive abuse and tooth and gingival damage.4,6,7

In a recent Internet search for tooth-whitening products, companies were easily found that offered up to 35 percent carbamide peroxide solutions on an OTC basis rather than the professional application for which they were intended. These products are advertised using phrases such as “the most preferred by top models, actors, executives, and athletes,” and “pure blend, high-intensity competitive strength gels are the finest quality overall that whiten best while causing the least amount of sensitivity.” At the same time, they claim that the use of fluoride, found in many “other” whitening products, slows down the whitening process.13 With these products readily available, it’s no wonder patients go to extremes to achieve that “Hollywood white” smile.

The Academy for Dental Facial Esthetics issued a warning to American consumers. Many products available make claims that could confuse or deceive consumers.10 As professionals, it is crucial that we recognize the potential for abuse and educate patients on the long-term implications. We can also assure patients that established bleaching techniques are successful and adequate to achieve whitening within safe guidelines.

A longitudinal clinical study published in the Journal of Esthetic Restorative Dentistry demonstrated that when used appropriately, a 10 percent carbamide peroxide whitening solution was effective in whitening teeth based on patient perceptions, and that 76 percent of patients at 47 months post-treatment still believed their teeth were whiter. Studies have also demonstrated that the average time to re-treat teeth is 25 months.14 With data such as this, we can assure patients that recommended treatment times are adequate for desirable shade changes.

The hygienist’s role in every aspect of patient care is to assess, diagnose, plan intervention, evaluate outcomes, and educate patients in oral health, including whitening abuse prevention. We should also stay abreast of current trends and products that our patients may use. One example of a product is the “white with might” whitening formula being developed at the ADA’s Paffenbarger Research Center. The ingredients will replenish essential minerals in teeth during the whitening process and cause fewer side effects.15 By recognizing that our patients’ perceptions are their reality, we can assure them about the appearance of their natural teeth and counsel them on safe treatments to acquire their desired look. We should commend our patients for their desire to achieve a white, healthy smile, and equip them with recommendations for attaining this goal without developing obsessive or damaging behavior.

Kathleen M. Harlan, RDH, MS, is a clinical assistant professor in the dental hygiene program at Ferris State University, in Big Rapids, Mich. She is first-year clinic coordinator of the associate degree program, and works in clinical practice when her teaching schedule allows.


1 Niessen LC. Talking with patients; tooth whitening: why, who, where, what and how. Journal of Esthetic and Restorative Dent 2001; 13:79.

2 Dunn WJ, Murchison DF, Broome JC. Esthetics: patients’ perceptions of dental attractiveness. Journal of Prosthodontics 1996; 5:166-171.

3 Freedman G. Whitening teeth: an idea whose time has come. Oral Health 1995; 85:13-22.

4 Bee P. Beyond the pale. London Sunday Times Feb. 5, 2006, pg 40. Retrieved from

5 ABC News Transcripts, Good Morning America; Teeth-Whitening Obsession, July 30, 2005. Retrieved from

6 ABC News Interview, ‘Bleachorexics’ Risk Much for White Smile: Feb. 3, 2005. Retrieved from 2/21/2006.

7 Thompson J. Dentists warn of the dangers of using do-it-yourself bleaching kits. Independent on Sunday (London), Newspaper Publishing PLC, 11/27/2005, pg 27. Retrieved from on 2/21/2006.

8 ADA Position & Statements: ADA Statement on the Safety and Effectiveness of Tooth Whitening Products; Feb. 2005, page updated, Aug. 5, 2005. Retrieved from

9 Nuss EF. How safe is tooth bleaching? The Dental Assistant 2004; 73:26-28.

10 Academy for Dental Facial Esthetics; Dental Health Experts Refute Misleading Teeth Whitening Claims; 5/11/2005. Retrieved from

11 Leonard RH, Misth LR, Garland GE, Caplan DJ. Desensitizing agent efficacy during whitening in an at-risk population. Journal of Esthetic and Restorative Dentistry 2004; 16:49-55.

12 Ritter AV. Talking with patients, over-the-counter tooth whitening. Journal of Esthetic and Restorative Dent 2003; 15(3):188.

13 Web site: Brighter Image tm. Lab Direct Teeth Whitening. Retrieved from, 3/13/2006.

14 Leonard RH, Bentley C, Eagle JC, Garland GE, Knight MC, Phillips C. Nightguard vital bleaching: a long-term study on efficacy, shade retention, side effects, and patients’ perceptions. J Esthet Restor Dent 2001; 13:357-369.

15 ADA News Release: New Tooth Whitener Could Help Heal Teeth; June 8, 2005. Retrieved from