Please Share This Valuable Information With All Doctors, Hygienists, and Assistants In The Office
Never before in the history of dentistry has a dental procedure received the amount of mass media promotion as vital tooth whitening. Improved esthetic treatment options have given the dental professional the ability to provide esthetic choices while preserving sound tooth structure. Vital tooth whitening is one of the esthetic choices the dental professional can offer to patients. Whitening is simple, noninvasive and inexpensive. Dr. James Dunn, whitening expert at Loma Linda University School of Dentistry in California, has commented that whitening is perhaps the only procedure in dentistry that is considered a pleasurable experience by patients. Dr. Dunn goes on to say that whitening is associated with the 1 perception of youth, health and beauty.
options. Over the counter (OTC) products contain various concentrations of carbamide peroxide or hydrogen peroxide. These products have been shown to cause gingival irritation or damage due to poorly contoured trays. The active ingredients in OTC products are acetic or citric acids that can cause loss of tooth 2 structure after repeated use.
Figure 2 recommended treatment time, isolation, 3 and suggested operator. For example, Illumine® (figure 1), 30 % hydrogen peroxide, is a 30-minute in-office system that does not require light or laser activation. Due to Illumine’s bioadhesive properties it does not require gingival isolation. Illumine is generally used as a boost.
Figure 1 In office systems such as Illumine™ (DENTSPLY Professional, York, PA) and Perfection White (Premier Dental Products Company, Plymouth Meeting, PA) are 30 to 35% hydrogen peroxide. In the April 2002 Dental Products Report on in-office bleaching systems Dr. Freedman recommends utilizing the following criteria. For selecting an in-office product: light activation, light sources, bleaching chemistry, desensitizers, home-bleaching adjunct,
The general public is confused about the different whitening options that are available. The current options include over-the-counter, dentist prescribed take-home, and in-office whitening systems. As dental professionals we have the opportunity and the duty to educate our patients about these whitening
Figure 3 A home-whitening adjunct such as NUPRO White Gold™(figure 2) or Perfecta® Bravo™ (figure 3) is recommended.
Sullivan-Schein Dental is an ADA CERP recognized provider.
Dentist prescribed take-home systems are 4.5 to 9% hydrogen peroxide or 10 to 22% carbamide or urea peroxide. Urea provides an acid pH that stabilizes the product during storage and extends the shelf life. Upon activation in the oral cavity, the urea by-products elevate the pH to an alkaline level that begins the whitening process within five minutes and keeps 4 the product active for several hours. Take-home systems are professionally monitored while offering the patient the convenience of using the product at home. The fee for take-home systems is usually reasonable. These systems are safe and effective and have clinically proven results. When evaluating a takehome product for effectiveness the following criteria can be helpful: a continuous release whitening agent with a neutral or palatable taste, high viscosity, and varied concentrations of carbamide peroxide.
Patients with yellow, orange or light musky brown teeth will usually achieve the best whitening results. Patients in the gray or bluish gray ranges will be less successful even after prolonged treatment. A behavioral habit such as smoking, coffee and tea drinking, and red wine consumption will influence results and must be considered. Other patient considerations are listed in table 1. Patients who are not likely to be compliant or patients whose expectations are unrealistic or unachievable may not be the best whitening candidates. For example, the color of the teeth should match the color of the white area (sclera) of the eyes. Teeth that are made whiter than one’s eyes can look unnatural.
prophy paste, and a topical fluoride treatment with NUPRO™ fluoride gel or All Solutions® rinse. An alginate impression of the arch to be lightened should be taken. DENTSPLY Professional recommends whitening one arch at a time to minimize occlusal discomfort as well as to enable the patient to see shade change. The patient must then be scheduled for tray delivery.
During the initial consultation, review the medical and dental history and conduct a comprehensive oral examination. Discuss the whitening system with the patient including expectations and considerations. Review any potential problems or side effects. For example, it can take one to three months to remove nicotine stains. Also, tetracycline stains tightly bond to dentin. The cervical third is the hardest to whiten because it contains the largest amount of dentin. Inform the patient that any existing tooth colored restorations may not match the lighter shade of teeth after the whitening treatment and will most likely need to be replaced. Wait one to two weeks post treatment before replacing any esthetic restorations due to residual oxygen remaining in the tooth which will cause a transient reduction in bond 5 strength. Make the patient aware that uneven white spots will blend over time. Once a treatment plan is formulated the patient should be scheduled for oral hygiene instruction, prophylaxis using the Cavitron Prophy Jet™ air polishing system or NUPRO™
The alginate impression is disinfected and thoroughly rinsed. The impression is poured in laboratory stone. Allow the stone to dry to an effective hardness. Trim the stone cast so that the base is parallel to the occlusal plane of the posterior teeth and extends two to four millimeters past the gingival border. In the case of a maxillary model, a drilled hole through the pallet will ensure a better fit on tooth surfaces when creating a tray. If creating reservoirs, apply an appropriate block-out gel such as Triad® Gel (DENTSPLY Caulk, York, PA) (figure 4). The gel will serve as a space that creates reservoirs in the whitening tray. Apply approximately a 1 to 1.5-mm thickness of the gel to the facial surfaces of the teeth to be whitened. When using the Triad® Gel a disposable dispensing tip that attaches to the end of the syringe for easy application is provided. Stay approximately 1 mm from the gingival margins and incisal/occlusal surfaces, avoid apply gel in interproximal areas. Cure the gel by applying a handheld curing light for 30 to 60 seconds per tooth, or place the model in the Triad®
TABLE 1 PATIENT CONSIDERATIONS
• Extremely large pulp chambers • Pulpal resorption • Existing hypersensitivity • Severe loss of enamel • Immature enamel • Extensive restorations • Peroxide allergy • Latex allergy • Pregnant or lactating • Behavioral habits • Lack of compliance • Patient expectations
Patient Selection and Treatment Considerations
Evaluation of the cause and extent of the stain is important for successful whitening. Causes of discoloration can be extrinsic, intrinsic or age related.
gingival margin. Lightly flame-polish the tray edges. Check for fit of tray on stone model. If the tray does not fit properly, use a flame torch to reapply and recontour the application tray where necessary. Wash and disinfect the whitening tray. Dry thoroughly and place in a storage case for delivery.
The whitening tray should be seated from side to side and excess gel wiped away. Instruct the patient on the use of the take-home shade guide. The patient will use the guide to document and date shade changes. Patients need to be aware of the saturation point. The saturation point is the point at which only hydrophilic colorless structures or stainless molecules exist. Optimal bleaching achieves whitening, over-bleaching degrades tooth enamel without further whitening.6 Post-daily treatment instructions include removing the tray, rinsing, and brushing and flossing to remove any residual whitening agent remaining on tooth surfaces. A separate toothbrush should be used to clean the tray, and then the tray should be stored in a case with mouthwash or water. Instruct the patient to call with any questions or concerns, and re-schedule for a follow-up.
Figure 5 Visible Light Cure (VLC) unit (DENTSPLY Caulk, York, PA) for two minutes (figure 5). Wipe the cured gel surfaces with alcohol-moistened gauze or cotton strip to remove excess material or oxygen-inhibited residue. Some manufacturers do not recommend the use of reservoirs.
Tray Delivery and Whitening Instructions
At the tray delivery appointment, the baseline shade will be documented. Also pretreatment photographs with and without the shade guide can be taken. The tray is tried in for proper fit and comfort. The whitening procedure is reviewed with the patient. The American Dental Association (ADA) recommends the use of a value oriented shade system that is sequenced by brightness. Factors influencing the shade determination are ambient light and the clinician’s vision. The ambient light should be consistent, neutral, reproducible and unbiased. Gender, age, genetics and distance can all affect the clinician’s vision. In general, the youngest female member of the dental team should be involved in the shade determination. Patient education should include loading and seating the tray. Review with the patient the teeth to be whitened. Demonstrate placing a small bead of the whitening agent along the front base of the tray and emphasize the importance of utilizing the proper dose of the whitening agent.
Figure 6 Place the tray material (pebble finish toward the model) on a heat/vacuum tray-forming machine. Soften the whitening sheet until it sags 1 to 2 inches. Engage the vacuum. Slowly lower the heated whitening tray onto the stone model. Allow ample time under the vacuum for optimal retention and definition. After the tray has cooled, remove it from the stone model. Using scissors, trim the tray approximately 2 to 3 mm beyond the teeth (figure 6). Trim and refine the remaining portion with precision scissors, scalloping around the interdental areas. Or trim the tray directly on the model using a soft tray trimmer such as Tray Magic™ (Premier Dental Products Company, Plymouth Meeting, PA) (figure 7). Trim the tray approximately .5 to 1 mm short of the
Whitening Success and Compliance
The number one reason for whitening success is compliance. Comprehensive and understandable patient education will ensure patient acceptance and is critical to whitening success. Despite claims that some whitening products do not cause sensitivity, double blind clinical studies have shown that sensitivity occurs in 55 to 75% of treatment.7 Treatment of tooth sensitivity can be active or passive. Passive treatment for sensitivity involves reducing treatment time or frequency of treatment, and interruption or cessation of the whitening treatment. Shorter wear time, such as 30 minutes once-a-day, as is recommended for Perfecta® Bravo™ (Premier Dental Products Co.) can help improve patient compliance.
Sensitivity can be treated actively through pretreatment with neutral sodium fluoride, application of an in-office fluoride treatment followed by a homeapplied fluoride, or use of other therapeutic agents. Haywood, et al recommend tray delivery of a 5% potassium nitrate – 1000 ppm fluoride gel.8 A comfortable, properly fitting tray, a palatable whitening agent with proper viscosity, and an appropriate delivery system are also critical to whitening success.
TABLE 2, MARKETING IDEAS Develop Gift Certificates for Life
Occasions Compile a Photo Album of “Successes” Use Statement Stuffers Whiten Staff Members Teeth One Arch at a Time Intraoral Camera Value Arranged Shade Operatory Display Posters/Brochures Telephone “On Hold” Message Target Mailing Website
Post-Visit and Marketing Ideas
Document the final shade, and take photographs with and without a shade guide. Obtain a testimony from the patient for marketing purposes. Review maintenance issues with the patient. Take-home treatment results typically last two to three years, while in-office treatments last four to five years.9 The goal of incorporating whitening into your practice should involve educating the patient about whitening. Marketing ideas for incorporating whitening into the practice are listed in table 2.
1. Dunn, JR. Whitening Symposium. Tufts University: Oct 2000. 2. Dunn, JR. Dentist-prescribed home bleaching: current status. Compendium 19(8): 760-764, 1998. 3. Freedman, G. In-office bleaching systems. Dental Products Report: April 2002. 4. Leonard, RH Jr, Haywood, VB, and Bentley, CD. Quintessence Int. 1994 Aug; 25(8): 547-550. 5. Goldstein, RE, Garber, DA. Complete Dental Bleaching 1995: 96. 6. Albers, H. ADEPT Report 1991; 2(1): 1-24. 7. Haywood, VB, Caughman, WF, Frazier, KB, and Meyers, ML. Tray delivery of potassium nitrate-fluoride to reduce bleaching sensitivity. Compendium 21(28): S10-S17, 2000.
8. Haywood, VB, Leonard, RH, Nelson, CF, and Brunson, WD. Effectiveness, side effects, and long-term status of nightguard vital bleaching. J Am Dent Asso. 1994 Sep; 125(9): 1219-1226. 9. Freedman, G. Yankee Dental Congress 1999. Sandra Marcil, RDH, MS, is the Southeast Clinical Educator for DENTSPLY International, Professional Division, York, PA. Ms. Marcil presents continuing education courses and academic lectures nationally on topics related to ultrasonic therapy, air polishing, tooth whitening and sealants. Ms. Marcil recently received her Masters of Science degree through a distance learning program at the Florida Gulf Coast University. She may be reached at: email@example.com or 727-298-8311.
COURSE SPONSOR Sullivan-Schein Dental is course sponsor. Sullivan-Schein Dental's ADA CERP recognition runs from November 2001 to December 2004. COURSE CREDITS All participants scoring at least 80% on the examination will receive a certificate verifying 3 CEUs. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. The current term of acceptance extends from December 2001 to December 2004. Participants are urged to contact their state dental boards for continuing education requirements. PARTICIPANT FEEDBACK If any participant wishes to communicate with the author of this course, please fax questions to: Sullivan-Schein Dental by fax to 1-800-781-6337. Be sure to provide us with the following information: name, address, e-mail address, telephone number, and course completed. RECORD KEEPING Sullivan-Schein Dental maintains records of your successful completion of any CE Seminars. Please contact our offices at Sullivan-Schein Dental, Attn: CEHP, 26600 Haggerty Rd., Farmington Hills, MI 48331, by mailing a note requesting a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.
IMPORTANT INFORMATION The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) and do not necessarily reflect those of Sullivan-Schein Dental. Completing a single continuing education course does not provide enough information to make the participant an expert in the field related to the course topic. It is a combination of many educational courses and clinical experiences that allows the participant to develop the skills, broad-based knowledge and expertise related to the subject matter. COURSE FEE/REFUND POLICY The cost for this course is $55.00. Any participant who is not 100% satisfied with this course can request a full refund by contacting: Sullivan-Schein Dental, Attn: CEHP, 26600 Haggerty Rd., Farmington Hills, MI 48331. COURSE EVALUATION We encourage participant feedback pertaining to all courses. Please be sure to complete the attached survey included with the answer sheet.
Sullivan-Schein Dental is an ADA CERP recognized provider.
©2002 Premier Dental Products Co.
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Value Pak (378-9671-VB) . . . . . . . . . . . . . .$128.49
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Patient Pak contains: 4 – 3cc syringes with dispensing tips, patient instructions with shade guide, doctor instructions, cosmetic patient travel pouch with mirror, EVA material and tray case.
1. Clinical Evaluation of the Bleaching Efficacy of Two Different Concentrations, Sheila H. Koh, D.D.S., F.A.G.D.UTHSC-Dental Branch; Esthetic Professionals-Dental Materials and Technology Update, July 2002.
Continuing Education Test Questions
Answer Sheet on Back Cover
1. Each of the following whitening options is professionally monitored except: a. in office b. over the counter c. dentist prescribed d. walking bleaching 2. In office whitening systems are generally 30- 35% hydrogen peroxide. Dentist prescribed take-home systems can range from 4.9 to 22% carbamide peroxide. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second is false. d. The first statement is false; the second is true. 3. An acid pH extends the shelf life of the whitening agent. An alkaline pH begins the whitening process within five minutes and allows the process to continue for several hours. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second is false. d. The first statement is false; the second is true. 4. Patients with yellow, orange or light musky brown teeth will usually have the best whitening results. a. True b. False 5. Evaluation of the cause and extent of the stain is not important for successful whitening. a. True b. False 6. Which of the following criteria are helpful in evaluating a take-home whitening system? a. high viscosity b. continuous release c. neutral or palatable taste d. all are helpful 7. Wait one to two weeks post whitening treatment before replacing any esthetic restorations. a. True b. False 8. Patient compliance is not critical to whitening success. a. True b. False 9. Which of the following is required for proper fabrication of whitening trays? a. pour model in stone b. trim the tray .5 – 1 mm from the gingival margin c. pour model in plaster d. both a & b 10. The ADA recommended value oriented shade system is sequenced by: a. brightness b. color c. eruption patterns d. age 11. Which of the following factors will influence the shade determination? a. ambient light b. clinician’s vision c. patient’s age d. both a & b 12. When selecting patients for whitening options which of the following should be considered? a. behavioral habits b. patient expectations c. extent of stain d. all of the above 13. Sensitivity occurs in 55 – 75% of whitening cases. a. True b. False 14. Sensitivity can be actively treated through pretreatment with neutral sodium fluoride. a. True b. False 15. Take-home treatment results typically last two to three years. In-office treatment results last four to five years. a. Both statements are true. b. Both statements are false. c. The first statement is true; the second is false. d. The first statement is false; the second is true.
Two years after her whitening,
Beth’s friends and family still look at her differently
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Number of Shade Changes from Baseline†
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End of Active Bleaching
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Reference: 1. Swift EJ, May KN, Wilder AD, Heymann HO, Bayne SC. Two-year clinical evaluation of tooth whitening using an at-home bleaching system. J Esthet Dent. 1999;11(1):36-42.
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For ordering information, contact your local DENTSPLY Professional distributor or call DENTSPLY Professional at 1-800-989-8826. www.professional.dentsply.com
Vital Tooth Whitening – The Gold Experience
Sandra Marcil, RDH, MS Sandra Marcil, RDH, MS
CONTINUING EDUCATION ANSWER SHEET
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After reading instructions: 1) Complete all information above. 2) Complete answer sheet with either a pen or pencil. All questions should have only one answer marked. 3) When test is completed, mail to:
Sullivan-Schein Dental Attn: CEHP 26600 Haggerty Rd. Farmington Hills, MI 48331
3 CE CREDITS
Course Fee $55.00
Please evaluate this course by responding to the following statements, using a scale of Excellent=4 to Poor=0. 1. The content was valuable: 4 3 2 1 0 The questions were relevant: 4 3 2 1 0 The course gave you a better understanding of the topic: 4 3 2 1 0 Rate the overall value to you: 4 3 2 1 0 Would you participate in a program similar to this one in the future on a different topic of interest: _____ Yes _____ No
Directions: Circle (A) for True and (B) for False
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