Clinical Tips to Ensure Successful Whitening Outcomes

INTRODUCTION
Tooth shade is known to significantly influence the aesthetics of a smile, and visible differences in teeth shades detract from overall appearance. Fortunately, tooth whitening repre­sents a minimally invasive yet powerful approach for achieving a smile makeover for a growing number of patients. In fact, it remains one of the safest, most conservative, and most effective options for patients wishing to enhance their smiles.¹ For dental professionals to successfully provide this treatment, an understanding of how and for whom whitening works, what tips and techniques can be employed to establish the foundation for successful whitening, and a working knowledge of which products offer the most effective results, are all key.²

Among the problems whitening treatment may correct are teeth discolored by endodontic treatments, medications, fluorosis, food, drink, and age.³ Although whitening is a noninvasive and generally safe procedure, it will not resolve all discoloration problems, nor should all patients take advantage of its benefits. Stains—ranging from yellow to brown—are usually more challenging to remove, but success has been shown with bleaching treatments.^4,5 Additionally, hypomineralized enamel lesions that appear as yellow or brown discolorations have also been successfully removed with tooth whitening.⁶ However, whitening veneers, crowns, and other restorations only affect the underlying tooth structure and around the margins. Patients with existing restorations are not ideal candidates for teeth whitening.

Additionally, several factors require consideration for whitening to be successful. Effective whitening treatment results from both the concentration of the bleaching agent(s) and length of exposure of the teeth to the whitening substance.^1,7 Since different whitening delivery systems offer varied concentrations of bleaching agents and are used for different lengths of time, an informed decision is also based on other criteria. For instance, patient compliance affects treatment success, and some whitening options (eg, at-home whitening trays) may not work as effectively for some patients as other delivery systems (eg, in-office bleaching).^8,9 Whitening procedures generally fall into one of 3 categories: (1) in-office whitening systems, (2) customized take-home trays, and (3) prefilled, disposable trays. To determine which product and strength would work best, dental team members should have an open and detailed conversation with their patients about their current habits to assess which treatment options will be best for patient compliance.

Once patients and dental team members have reached a mutual decision on the whitening procedure, team members can take several proactive steps to ensure a successful outcome. Taking a complete set of clinical photographs (including a full-face, smile, and retracted smile with shade tab) gives both patients and dental professionals a clearer picture of what this whitening procedure can and ultimately will achieve. Take full-face photographs utilizing a solid and non-distracting background to provide contrast to the patient. For smile photographs, encourage the patient to give an exaggerated smile that shows as many teeth as possible. For retracted smile photographs, frame the image to include the patient’s upper and lower lips, with the camera on the same level as the patient, and place a VITA shade guide to document the shade of their preoperative whitening smile.

When treating patients for whom custom trays are needed, detailed impressions are needed to ensure that the trays fit properly. Impressions can be taken using several different materials (such as alginate, alginate substitute, or vinyl polysiloxane). However, once impressions have been taken, dental team members should carefully inspect them for any voids, bubbles, or distortions; if the impressions demonstrate any of the aforementioned problems, then they should be retaken, so the fit of the trays is not compromised.

Many Whitening System Options
Equally significant to successful whitening outcomes are knowledge and understanding of available material options. Fortunately, today’s clinicians have many excellent products from which to choose.

One line of innovative whitening products, which will be demonstrated and discussed in this article, can provide the clinician with several options to satisfy the majority of patients’ whitening needs—Opalescence (Ultradent Products). When treating patients for whom in-office bleaching is ideal, a chemically activated power whitening gel (Opalescence Boost [Ultradent Products]) only requires 40 minutes in the dental chair for a significantly brighter smile. Because this 40% hydrogen peroxide gel is chemically activated, it does not require a light source to achieve a highly significant whitening outcome. Opalescence Boost can be used for whitening one or more teeth, parts of a tooth, and/or for accelerated chairside whitening techniques. It contains potassium nitrate, which has been shown to help reduce tooth sensitivity, and fluoride to help reduce caries and strengthen enamel.^10,11 To reduce potential soft-tissue irritation, apply vitamin E moisturizing oil to the patient’s lips, or use an expanding liquid gingival barrier to protect the soft tissues.

An effective at-home alternative for use with customized whitening trays is Opalescence PF (Ultradent Products). This product is a whitening gel that also contains both potassium nitrate and fluoride to reduce sensitivity and strengthen enamel, as well as 20% water to prevent dehydration.^10,11 The unique formula prevents shade relapse and is also highly viscous, ensuring it remains in place without slumping or migrating to the soft tissues. Available in 3 flavors and 4 concentrations for treatment flexibility, the ideal active ingredient strength can be selected to ensure treatment compliance.

When a more convenient option is needed, Opalescence Go is ideal. The professionally dispensed, prefilled tray design allows the gel to contact posterior teeth, providing complete whitening coverage. These convenient prefilled trays are available in 3 different flavors in 10% hydrogen peroxide concentrations (with wear times from 30 to 60 minutes) and 15% hydrogen peroxide concentrations (with wear times from 15 to 20 minutes). Requiring no impressions or models, Opalescence Go provides professional whitening that is more effective than over-the-counter options and can also be used as a follow-up to in-office whitening or for as-needed touch-ups. In particular, Opalescence Go is ideal for a patient whose starting shade falls in the A or B range, and who doesn’t consume much wine, hot tea or coffee, or dark sodas. Patients whose discoloration falls in the C and D range, who also frequently consume foods and beverages that contribute to tooth staining, would benefit most from take-home whitening using Opalescence PF with custom trays. Additionally, these patients should be educated about the need to re-whiten every 2 to 3 years.

CASE REPORTS
Case 1
A 24-year-old female presented in response to a whitening treatment promotion that she received via email. She had always wanted to whiten her teeth, but college expenses limited her discretionary spending. She presented with moderate to severe biofilm accumulation and darkening teeth due to consumption of soft drinks and sweetened iced tea (Figures 1 and 2).

The patient’s tooth shade was determined using a standard VITA shade guide (Figure 3), and the prewhitening shade was photographed using a digital camera designed specifically for dental applications (EyeSpecial C-II [Shofu Dental]). The patient’s pretreatment shade was determined to be A2.

Given the patient’s lifestyle and financial situation, a 10-pack of prefilled whitening trays containing 10% hydrogen peroxide (Opalescence Go, 10%) was prescribed. As a result, no impressions were needed, since the specially designed trays conform to the patient’s arches.

CASE 1 Figure 1. Pre-op full-face photo. Figure 2. Pre-op smile photo. Figure 3. Pre-op photo with A2 shade tab. Figure 4. Shade monitoring was done at 3-day follow-up appointment. Figure 5. At the 2-week follow-up appointment, the patient’s shade was determined to be B1. Figure 6. Post-op full-face photo.

To ensure patient compliance and understanding of the proper use of the prefilled trays, the first treatment was completed in the office, and the patient was dismissed. She was asked to return in 3 days to monitor her shade change. At the 3-day follow-up appointment her shade was taken, and it was A1 (Figure 4). At the 2-week follow-up appointment, the patient’s whitened tooth color was determined to be B1 (Figures 5 and 6).

Case 2
A 32-year-old male presented with a chief complaint of disliking his smile due to discoloration (Figure 7). He also was responding to an emailed whitening promotion. A former smoker and heavy barbecue and hot sauce eater, his teeth were very sensitive to cold. The patient, a very busy firefighter, had always wanted to whiten his teeth, but cost and finances were an issue.

The patient’s tooth shade was determined using a standard VITA shade guide at A3.5 (Figure 8), and the prewhitening shade was photographed using a digital camera (EyeSpecial C-II).

Given the extent of tooth discoloration, and his tooth sensitivity, a 10-day pack of prefilled whitening trays containing 15% hydrogen peroxide (Opalescence Go, 15%) was prescribed. The addition of potassium nitrate and fluoride would help to reduce sensitivity, improve overall health of the teeth, and strengthen the enamel.^10,11

CASE 2 Figure 7. Pre-op photo of patient. Figure 8. Pre-op photo with A3.5 shade tab. Figure 9. (a) Post-op shade was B1, after 10 days of whitening. (b) Post-op photo.

Patient compliance and understanding of how to properly use the prefilled trays was assured by conducting the first application in the office. At the 2-week follow up appointment, the patient’s whitened tooth color was determined to be B1 (Figure 9).

Case 3
A 14-year-old female presented with very yellow teeth, which she had exhibited from a young age (Figure 10). As she progressed through adolescence, the discoloration worsened, and she was very embarrassed by the color of her teeth, particularly because she was captain of her cheerleading squad. Her embarrassment and tooth discoloration were compounded by the fact that she had just completed traditional orthodontic treatment. She stated that, “The braces hid the color of my smile until they were removed, and now my teeth are the color of my hair!”

CASE 3 Figure 10. Pre-op photo of patient. Figure 11. Pre-op retracted photo with shade tab A3. Figure 12. Post-op photo.

A standard VITA shade guide and digital photographs were used to determine and record the patient’s prewhitening shade of A3 (Figure 11). Given the patient’s age and active lifestyle, a 4-day pack of prefilled whitening trays containing 10% hydrogen peroxide (Opalescence Go, 10%) was prescribed.

According to the American Academy of Pediatric Dentistry, patients (and their parents) who are considering tooth whitening treatments should consult their dentists to ensure judicious and proper whitening that utilizes the appropriate whitening technique.¹² Whitening studies focused on children and adolescents have found whitening treatments to be effective, with the only adverse effects being those commonly experienced, such as hypersensitivity.^13-15 However, the potassium nitrate and fluoride contained in the 10% Opalescence Go formula would help to reduce sensitivity, improve overall health of the teeth, and strengthen the enamel.^10,11

Patient compliance and understanding of how to properly use the prefilled trays was assured by conducting the first wear in the office. At the 2-week follow-up appointment, the patient’s whitened tooth color was determined to be B1 (Figure 12).

CLOSING COMMENTS
Many patients want to improve their smiles with minimally invasive procedures such as teeth whitening. Therefore, to ultimately achieve the best clinical outcomes possible, it behooves all dental team members to remain up to date on the intricacies of the latest whitening materials, delivery systems, and techniques to maximize success. Equally important is taking proactive steps (such as ensuring detailed impressions and obtaining complete clinical photographs) to meet the patients’ expectations. Then, with the myriad whitening alternatives readily available to dental professionals and patients, careful and thoughtful selection of the appropriate whitening product option should be made, based on clinical findings and the specific patient needs.

References

1. Sarrett DC. Tooth whitening today. J Am Dent Assoc. 2002;133:1535-1538.
2. American Dental Association. For the dental patient. Tooth whitening: what you should know. J Am Dent Assoc. 2009;140:384.
3. Sulieman M. An overview of tooth discoloration: extrinsic, intrinsic and internalized stains. Dent Update. 2005;32:463-471.
4. Kugel G, Gerlach RW, Aboushala A, et al. Long-term use of 6.5% hydrogen peroxide bleach strips on tetracycline stain: a clinical study. Compend Contin Educ Dent. 2011;32:50-56.
5. Matis BA, Wang Y, Eckert GJ, et al. Extended bleaching of tetracycline-stained teeth: a 5-year study. Oper Dent. 2006;31:643-651.
6. Wright JT. The etch-bleach-seal technique for managing stained enamel defects in young permanent incisors. Pediatr Dent. 2002;24:249-252.
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8. Potgieter E. Grobler SR. Whitening efficacy of three over-the-counter oral rinses. SADJ. 2011;66:128-131.
9. Majeed A, Grobler SR, Moola MH, et al. Effect of four over-the-counter tooth-whitening products on enamel microhardness. SADJ. 2011;69:412-415.
10. Wang Y, Gao J, Jiang T, et al. Evaluation of the efficacy of potassium nitrate and sodium fluoride as desensitizing agents during tooth bleaching treatment—a systematic review and meta-analysis. J Dent. 2015;43:913-923.
11. Tam L. Effect of potassium nitrate and fluoride on carbamide peroxide bleaching. Quintessence Int. 2001;32:766-770.
12. American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on dental bleaching for child and adolescent patients. Pediatr Dent. 2008-2009;30(suppl 7):61-63.
13. Donly KJ, Segura A, Henson T, et al. Randomized controlled trial of professional at-home tooth whitening in teenagers. Gen Dent. 2007;55:669-674.
14. Croll TP, Segura A. Tooth color improvement for children and teens: enamel microabrasion and dental bleaching. ASDC J Dent Child. 1996;63:17-22.
15. Donly KJ, Donly AS, Baharloo L, et al. Tooth whitening in children. Compend Contin Educ Dent. 2002;23:22-28.

Ms. Pace Brinker has been a full-time practicing dental assistant for more than 23 years and serves as a consultant and educational trainer to many dental manufacturers. She and her team teach more than 200 lecture and hands-on classes per year. She holds the Chairside Dental Designer certification from Planmeca and the Align Certificate of Excellence from Align Technologies. An international speaker and published author, she has been one of Dentistry Today’s Leaders in Continuing Education since 2009. She was selected as one of Dental Products Report’s 25 Most Influential Women in Dentistry and named Dr. Bicuspid’s Dental Assisting Educator of The Year in 2012. She also received the American Academy of Cosmetic Dentistry’s Rising Star Award in 2013. She can be reached at shannon@cpsmagazine.com.

Disclosure: Ms. Pace Brinker reports no disclosures.