As interest in esthetic dentistry continues to increase, it becomes ever more important to educate our patients about whitening options—OTC products, professional take-home treatments, and in-office options—to make that trip down the oral health-care aisle less overwhelming.
Botox, plastic surgery, cosmetic dentistry . . . it’s all around us. Simply look at the magazines in the checkout lane in the grocery store or take a stroll down the oral health-care aisle. The expanse of this aisle contains every variety of toothbrush, floss, and toothpaste available to consumers. In 2017, National Public Radio reported that more than $3 billion is spent globally on whitening products, and the trend was expected to continue to rise.1 This increase can be attributed to the fact that people have more disposable income, an increased awareness of esthetics, and the desire to maintain a youthful appearance compared to previous generations. A smile can be a greeting, perception, display of emotions, and leave a lasting social impression. According the American Academy of Cosmetic Dentistry, 99% of all people believe that their smile is the most important social feature.2 These statistics are in direct alignment with the World Health Organization’s model of oral health.3
Dental stains and whitening go hand in hand. Whitening cannot be discussed without identifying the types of stain with which a patient may present. The type of stain may determine the type of whitening and its outcome. Stains are classified into two major categories based on their location on the tooth: extrinsic and intrinsic. Extrinsic stain is staining on the surface of the tooth and can be removed with scaling and/or polishing, whereas intrinsic stain impacts the internal structure of the tooth and cannot be removed simply by scaling, but it can be lightened with the use of whitening agents. Intrinsic stain is the most influential and is ultimately predetermined by genetics and other inherent factors.
Common extrinsic stains
These are the common types of extrinsic stains:
Black stains: These stains are typically found on both primary and permanent dentitions in patients with good oral hygiene and low caries rates. Black stain can also be the result of taking iron supplements or appear on the facials of anterior teeth and occlusal posteriors of patients with poor oral home care.4–6 Stannous fluoride will also cause black staining along the smooth surfaces of the teeth.
Brown stains: These stains are commonly seen in patients who drink coffee, tea, wine, and/or use tobacco products. This is due to the pigments present in these products. Another common cause of brown staining is the use of chlorhexidine. This can be seen in the interproximal spaces or on the smooth surfaces of the dentition.
Yellow/brown/green stains: Plaque and calculus as a result of poor oral hygiene can present with these colors of stains.
Common intrinsic stains
These are the most common types of intrinsic stains:
Gray stains: A tooth that has pulpal necrosis/trauma can take on a gray appearance. Gray stains can also occur in areas where amalgam restorations have been placed.
Brown stains: These stains accumulate around margins of composite restorations. Brown spotted stains can also be indicative of fluorosis.
White stains: White stains are typically indicative of demineralization and fluorosis. Fluorosis may appear as white/milky spots; the enamel may be mottled or pitted but will not have bands of dark colors.7
Dark bands: Although the Food and Drug Administration (FDA) has advised cautionary use of the antibiotic tetracycline during pregnancy and in young children, this condition is still seen clinically. The location of the dark coloration depends on what developmental stage the tooth was in when the medication was taken.
ADA Seal of Acceptance
Now that we’ve quickly reviewed the most common types of intrinsic and extrinsic stains, let’s get back to the endless oral hygiene aisle. Like vitamins, whitening agents are not controlled or approved by the FDA, but some products do carry the American Dental Association (ADA) seal. Any product displaying the ADA Seal of Acceptance has been tested by an independent panel of dentists for safety and effectiveness. This has been the recognized gold standard in dentistry since 1931 in an effort to help dental professionals make educated and scientifically backed product recommendations.1
If a product does not carry the ADA seal, it does not mean that the product is not effective; it means that the efficacy and product claims have not been scientifically tested by the ADA. The ADA Seal of Acceptance is valid for five years after it is issued for a product, during which time all necessary data must be maintained and/or updated.8 While there are a variety of over-the-counter (OTC) whitening products to choose from, there are only a handful of products that have the backing of the ADA.
At-home whitening products9
These are the at-home whitening products that have the ADA Seal of Acceptance:
- Crest 3D White Whitestrips (Glamorous White)
- Crest 3D Whitestrips Classic Vivid
- Crest 3D Whitestrips Gentle (Brilliance Gentle, Vivid Gentle, and Gentle Routine)
These are the whitening toothpastes that have the ADA Seal of Acceptance:
- Colgate Total Advanced Deep Clean Toothpaste
- Colgate Total Advanced Fresh+Whitening Gel Toothpaste
- Colgate Total Clean Mint Paste
- Colgate Total Mint Stripe Toothpaste
- Crest Pro-Health Advanced Deep Clean Mint Toothpaste
- Crest Pro-Health Extra Whitening Power Toothpaste
- Crest Pro-Health Toothpaste (Cool Spearmint, Intense Peppermint)
- Tom’s of Maine Simply White Clean Mint Toothpaste
- Tom’s of Maine Simply White Sweet Mint Gel Toothpaste
Types of whitening systems
Whitening systems are available in both OTC products, professional take-home treatments, and in-office options. All treatment options will achieve a whiter smile but when making a recommendation, the patient’s expectations need to be taken into consideration. Some OTC products will achieve a whiter smile but may take longer to get results, or they may not achieve the type of results that professional whitening systems could provide. The type of stain that patients present with will also impact how many shades lighter a tooth will whiten.
For example, patients with stains on the gray scale will be more difficult to get bright white compared to teeth with a yellow shade. Patients with recession and dentinal sensitivity will likely experience sensitivity during treatment and for a short time thereafter. Cost may also be a factor when choosing the right whitening options. According to a national dental fee survey conducted in 2018 by the American Dental Association, in-office whitening can range from $150 to $500 per arch; take-home trays can average $100 to $450 per arch; and OTC whitening systems can range from $20 to $100.11
Take-home whitening systems will best address intrinsic stains; however, extrinsic stains may still need to be removed prior to beginning treatment. When choosing an at-home whitening system, it is important to explain the possible side effects to patients as well as stress the importance of making sure that the tray/strips fit properly to avoid caustic burns on the gingival tissues. The most common side effect patients experience during whitening is dentinal sensitivity.
Opalescence Go 15% (Ultradent) contains 15% hydrogen peroxide and has a tray system, similar to Crest 3D Whitestrips, which contains 10% hydrogen peroxide. In a study published in Clinical Oral Investigations, participants who used a 15% hydrogen peroxide gel presented with better color stability than the participants who were given a 6% hydrogen peroxide gel.12 The advantage of recommending Opalescence Go is that it also contains potassium nitrate as well as fluoride.
For patients interested in custom trays and a take-home gel, I frequently recommend either Philips Zoom NiteWhite 22% CP gel syringes (also available in 22% CP+ACP) or Opalescence PF, which is available in a 10%, 15%, 20%, or 45% solution. Philips Zoom NiteWhite 22% is a great product that offers a whiter smile and also addresses patient sensitivity. This particular product contains 5% potassium nitrate to combat secondary sensitivity due to whitening.13 Just like Opalescence Go, Opalescence PF contains potassium nitrate and fluoride.
Certainly, the quickest way to achieve a whiter smile and combat intrinsic staining is to have an in-office whitening treatment, but this is usually the most expensive option for patients. From a cost perspective, patients can typically get esthetically pleasing results with take-home tray systems. If time or treatment constraints are considerations, in-office whitening options should be discussed with patients.
Toothpastes and whitening
One of the most common questions patients ask me is, “What kind of toothpaste do you recommend?” The most important criteria that I look for is whether the product contains fluoride and what the patient’s expectations or needs are—e.g., whitening, baking soda, sensitivity, gingivitis. Whitening toothpaste provides the most cost-effective option to whiten teeth; however, this option can take on average four to six weeks to whiten, frequently with a significantly less dramatic change in brightness.
Whitening toothpastes often have a whitening agent, either hydrogen peroxide or carbamide peroxide, in addition to an abrasive agent to assist in removing extrinsic staining. In these toothpastes, the primary mode of action is the mechanical removal of stained pellicle, which removes extrinsic stain in the process.
In a study conducted in 2018, researchers compared academic literature on the effectiveness of whitening toothpaste versus nonwhitening toothpaste. Results revealed that whitening toothpastes can be effective but recommended that additional studies be conducted using the same research methods.14 Due to the abrasiveness of whitening toothpastes on the enamel and pigments in the biofilm, the chromogenic bacteria are unable to adhere to the tooth’s surface as easily as a traditional toothpaste and will reduce extrinsic stain. Within the limitations of the research, results have concluded that the abrasiveness of whitening toothpastes can contribute to whitening results on dentition.15
One toothpaste that I commonly recommend is from Tom’s of Maine. Their products are all natural and, specifically, Tom’s of Maine Simply White has received the ADA Seal of Acceptance. Tom’s of Maine Simply White in either Clean Mint or Sweet Mint contains hydrated silica, which is an abrasive agent used to both clean and whiten the enamel. In addition to the hydrated silica, this product also contains 0.24% sodium fluoride.16 What I really like about this product is that it appeals to a wide range of customers—those who prefer a more natural option as well as those who want to address esthetic concerns.
Due to the limited number of studies on whitening toothpastes and their effectiveness, the ADA Seal of Acceptance would serve as a good starting point for product recommendations.
Our duty to educate patients
When choosing which whitening products are best to recommend, the options are endless. Ultimately, patients’ needs, expectations, and financial limitations should be taken into consideration. With the projected increase in interest in esthetic dentistry, the number of whitening cases and options will continue to rise. It is our duty as dental professionals to make sure that we educate our patients about the types of stains on their teeth, as well as which products are available to them both OTC and in-office. The risk of not properly educating our patients about whitening is great, and it can impact their dentition over the long term if they do not understand which products best meet their needs. By providing guidance to our patients, we can make the trip down the oral health-care aisle less overwhelming and confusing.
1. Neighmond P. Navigating the ‘aisle of confusion’ to whiten your teeth. National Public Radio website. https://www.npr.org/sections/health-shotws/2017/08/14/542830158/navigating-the-aisle-of-confusion-to-whiten-your-teeth. Published August 14, 2017. Accessed June 8, 2019.
2. Handzel S. Demand for cosmetic dentistry expected to increase in coming years. Dentist’s Money Digest website. https://www.dmdtoday.com/news/demand-for-cosmetic-dentistry-expected-to-increase-in-coming-years. Published September 23, 2016. Accessed June 8, 2019.
3. Bersezio C, Martin J, Herrera A, Loguercio A, Fernández E. The effects of at-home whitening on patients’ oral health, psychology, and aesthetic perception. BMC Oral Health. 2018;18(1):208. doi:10.1186/s12903-018-0668-2. https://www.ncbi.nlm.gov/pmc/articles/PMC6290526. Accessed June 6, 2019.
4. Mortazavi H, Baharvand M, Khodadoustan A. Colors in tooth discoloration: A new classification and literature review. Int J Clin Dent. 2014;7(1):17-28. http://www.researchgate.net/publication/262294748. Accessed June 8, 2019.
5. Sulieman M. An overview of tooth discoloration: extrinsic, intrinsic, and internalized stains. Dent Update. 2005;32(8):463-464, 466-468, 471. doi:10.12968/denu.2005.32.8.463.
6. Neville B, Damm D, Allen C, Bouquot J. Oral & Maxillofacial Pathology. St. Louis, MO: Saunders; 2009.
7. Jeong C. Teeth staining summary by color and origin for the dental hygiene exams. DentistryIQ website. http://www.dentistryiq.com/dental-hygiene/article/16352576/teeth-staining-summary-by-color-and-orgin-for-the-dental-hygiene-exams. Published June 17, 2016. Accessed June 5, 2019.
8. Department of Scientific Information; ADA Science Institute. Oral health topics > Whitening. American Dental Association website. http://www.ada.org/en/member-center/oral-health-topics/whitening. Accessed June 11, 2019. Updated August 29, 2019.
9. Clinical resources > ADA Accepted Bleaching products. American Dental Association website. http://www.ada.org/en/science-research/ada-seal-of-acceptance/ada-seal-products/product-category?category=Bleaching+Products. Accessed June 11, 2019.
10. Clinical resources > ADA Accepted Toothpastes with at least these attributes: Stain removal. American Dental Association website. http://www.ada.org/en/science-research/ada-seal-of-acceptance/ada-seal-products/product-category?attributes=Stain+Removal. Accessed June 11, 2019.
11. American Dental Association. Health Policy Institute. 2018 Survey of Dental Fees; 2018. https://success.ada.org/en/practice-management/finances/survey-of-dental-fees.
12. Maran BM, Ziegelmann PK, Burey A, de Paris Matos T, Loguercio AD, Reis A. Different light-activation systems associated with dental bleaching: a systematic review and a network meta-analysis. Clin Oral Investig. 2019;23(4):1499-1512. doi:10.1007/s00784-019-02835-x. http://link.springer.com/article/10.1007%2Fs00784-019-02835-x. Accessed July 1, 2019.
13. Philips Zoom NiteWhite 22%. Philips Zoom website. http://www.usa.philips.com/c-m-pe/dental-professionals/products/whitening/take-home-whitening/nitewhite-quick. Accessed July 12, 2019.
14. Casado BGS, Moraes SLD, Souza GFM, et al. Efficacy of dental bleaching with whitening dentifrices: A systematic review. Int J Dent. 2018;2018:7868531. doi:10.1155/2018/7868531.
15. Vaz VTP, Jubilato DP, Oliveira MRM, et al. Whitening toothpaste containing activated charcoal, blue covarine, hydrogen peroxide or microbeads: which one is the most effective? J Appl Oral Sci. 2019;27:e20180051. doi:10.1590/1678-7757-2018-0051.
16. Tom’s of Maine Oral Care, Clean Mint Simply White Toothpaste. Tom’s of Maine website. http://www.tomsofmaine.com/products/oral-care/simply-white-toothpaste. Accessed July 12, 2019.