Tooth whitening 101 – part two – Dentistry Online

Dentistry Study Club hosted various webinars with Andy Wallace, Megan Fairhall and Affan Saghir on tooth whitening recently. Here is the second in a five part series covering everything you need to know about offering tooth whitening in your dental practice.

Lockdown has been an opportunity for the dental profession to catch up on their education.

Philips Oral Healthcare sponsored a number of webinars on tooth whitening. The Philips team were delighted to see how so many dentists, hygienists and therapists were enthusiastic to learn more about the subject.

Aerosol-free tooth whitening is an attractive practice builder, which can involve the whole dental team. Here are the questions and answers provided by Dr Affan Saghir, Dr Andrew Wallace and dental hygienist Megan Fairhall during their webinars.

Suitability

Which whitening treatment may suit which patients?

Megan Fairhall: Patients who would like to consider tooth whitening need to book in with their dentist and get a prescription to see their hygienist or therapist.

There are naturally important factors to look into before going ahead with any whitening procedure.

The dentist needs to carry out a full examination. After which they make a referral to a hygienist and therapist to devise a whitening treatment plan.

I essentially work with the Zoom in-chair treatment and the Philips take home trays.

Whitening toothpastes don’t contain enough hydrogen peroxide to have any whitening effect. They are just more abrasive. If, however some people have stains, an ongoing use may not be negligible.

Regular oral hygiene and airflow to maintain the colour of their teeth are good too.

Can patients with caries or root-treated teeth have their teeth whitened?

Affan Saghir: The health of a patient is the most important thing, over the aesthetics of the teeth.

Before a whitening appointment can take place, a patient needs to visit the hygienist and have a caries assessment. The gums and perio conditions need to be healthy ahead of treatment.

Crowns or veneers won’t whiten in the same way as normal teeth. But the treatment will help to lift extrinsic stains – although this is virtually insignificant.

You can carry out internal whitening on teeth with a root canal. You will need to make a hole on the palatal aspect where the cavity is. Place the GIC lining and leave the hole open. Tell your patient to place the gel on the tray aligned with this hole and put the tray in. The carbamide peroxide will help cleanse the area out and will whiten the tooth.

Can breastfeeding patients have their teeth whitened?

Andrew Wallace: I do not whiten teeth for pregnant or breastfeeding mothers.

How do you whiten teeth with white spots?

Megan Fairhall: When you whiten teeth that have white spots, you need to be aware that these areas may whiten quicker because they are more porous.

For that reason, I tend to use a lower percentage gel of 10% carbamide peroxide.

It is important to pre-warn patients to manage their expectations. When the whitening process has stabilised, which takes about two weeks, these spots will die down. The aim is to get these white spots to become more uniform with the teeth.

There can be amazing results. Every case is different so do keep talking to patients.

What should we include in the prescription for tooth whitening?

Megan Fairhall: The medical history and dental history need factoring in. That can also include a radiograph, whenever required.

It is important to identify and take into account if there are any anterior restorations, crowns, bridges and implants. Highlight these as they won’t whiten and may need replacing afterwards.

If there are any white or brown spots, extrinsic or intrinsic staining maybe due to fluorosis or tetroxide staining. These need looking at carefully when offering the treatment.

Single yellow teeth may need a different whitening process, which would need mentioning to the patient.

You also need to assess the gingival health of the patient and suggest any hygienist appointments beforehand. Same if there is any active disease, perio or caries, recession.

Finally, sensitivity is another factor of importance. It is essential that a discussion is done on the subject. Look at preventive measures and manage patient’s expectations too.

What would you recommend if one tooth is more discoloured than the rest?

Andrew Wallace: First I will want to find the reason why that tooth is discoloured.

The approach depends on the reason. But if the tooth is vital, I will get the patient to start with that one dark tooth and get it as white as it will go. Then whiten the other teeth to match.

If the patient has very translucent greyish teeth do you have any tips for whitening them?

Andrew Wallace: As mentioned in the webinar, this is due to translucency and whitening has a limited effect on this. It may be the cause of the translucency (pathway wear often) will need addressing restoratively.

What about dental erosion and whitening?

Andrew Wallace: It is important to take a proactive approach to managing sensitivity before and during whitening then restoratively address the tooth surface loss.

Sensitivity

What sensitivity can patients expect? Can anything help reduce sensitivity, for example mousse or toothpaste?

Affan Saghir: Patients will experience sensitivity. It’s important to manage expectations otherwise they won’t be compliant.

I tell my patients the sensitivity is a sign the solution is working. They have to stick to it every night otherwise it won’t work.

ACT or fluoride toothpaste will reduce sensitivity, as will a toothpaste with a de-sensitising action. This may also help with the lustre of the teeth too.

How do you approach sensitivity?

Megan Fairhall: Sensitivity is unpredictable. Prevention and management are key.

I find that the Zoom in-chair procedure is the one that causes the least sensitivity. Plus, this means that the take home trays are only used for a few days as opposed to weeks. That way, you increase compliance and patients get the best results.

Patients can also use a sensitive toothpaste, ideally two weeks prior to the whitening. It takes that amount of time to kick in.

However, ingredients in some sensitive toothpastes can inhibit the whitening, so watch out.

I also recommend the Philips ACP gel. I have used it myself and swear by it.

Have you ever faced a patient with severely sensitive teeth after whitening and how do you manage this?

Andrew Wallace: Rarely. Using the protocol described in the webinar; taking a history, starting two weeks of desensitising paste, Philips Daywhite, ACP gel, Gluma Desensitiser, slow start, skipping a day if needed. I find I can mange the sensitivity of almost all patients.

Do you recommend patients to take Ibuprofen for post bleaching sensitivity or pain?

Andrew Wallace: They can do.

In a patient with tooth wear occlusally and sensitivity due to it, would the added sensitivity be a factor to lead us to avoid whitening? At least until the tooth wear is restored?

Andrew Wallace: If the sensitivity is managed with the previously described protocols, it avoids having to replace the restorations to match the new colour.