Tray Tooth Bleaching Sclera of the Eyes

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best when they match the color of the 5 Tray tooth bleaching sclera of the eyes. The right thing at the right time Prior to bleaching, the dentist should conduct a proper 2 examination and analysis of By Van B. Haywood, DMD (according to the wisdom of my the smile. This examination should include: f you rob a bank and give the late esteemed colleague Dr. Dick t Evaluating how much of the money to the poor, have you Tucker). teeth are showing in a full smile done the right thing? If you When considering bleaching, the I most cost-efficient, safe and effica- because the gingival area of teeth restore teeth with the best possible do not bleach as well as the incisal porcelain veneers when the teeth do cious technique for both the dental portion. not need veneers, have you done the office and the patient is generally t Identifying the gummy smile be- right thing? recognized as tray bleaching using a cause whiter teeth make the gummy Bleaching teeth is one of the 10 percent carbamide peroxide (CP). smile more noticeable. Periodontal many treatments that everyone The following checklist on tray therapy for altered passive eruption should have in their treatment op- bleaching may be helpful. may be first indicated. tions in order to do the right thing Everybody’s teeth respond t Identifying the existing restora- at the right time. Once you have differently, both in how white tions revealed in a full smile because determined to do the right thing, 1they get and how quickly that the restorations do not change color. then you need to do the thing right whitening occurs. Tray bleaching t Evaluating the results of the expectations include: periodontal conditions because t Normally discolored teeth can exposed roots do not bleach. take three days to six weeks. t Recording all existing decay, t Nicotine-stained teeth can take gingival disharmony, history of sen- one to three months. sitivity or occlusal problems. t Tetracycline-stained teeth can take two to 12 months or longer. The dentist should take a The average for tetracycline-stained screening radiograph of the an- teeth is three to four months to get 3 terior teeth to be bleached and lighter, but not necessarily white. any single dark tooth to determine Once teeth reach their maximum the cause of the discoloration. That whiteness, further treatment or dif- cause could include: ferent products or concentrations will t An abscessed tooth. not improve that shade. Teeth look the 6HH%/($&+,1*SDJH

DentalPracticeSuccess SPRING 2016 BLEACHING ide), so trays can be made that Continued from page 5 extend onto the tissue 1-2 mil- limeters for a more comfortable, better seal. The gingival health in t Internal or external resorption. research projects always improves t Calcific metamorphosis (the during bleaching. Concentra- pulp chamber obliterated by second- tions higher than 10 percent ary dentin). require scalloping the tray such t Different size pulp chambers. that there is no tissue contact to t Caries. avoid tissue burning. t Cysts or tumors. Spacers or reservoirs are There are two different bleach- not needed to bleach teeth ing materials that require as only a thin film of mate- 4 different instructions for the 7 rial is required with tray isola- patients. CP is composed of hydro- tion, but reservoirs account for geng peroxide and urea. CP is best tight or ill-fitting trays. A proper wornw overnight, as it is active for 6 to alginate impression (where the 101 hours. Hydrogen peroxide (HP) is adhesive has set for 10 minutes onlyo active for 30 to 60 minutes, so 6 in the tray before use, the impres- iti is applied during the day. A 10 per- sion is held in the mouth for one centc CP product is comparable to a minute past tacky and poured 3.53 percent HP product. Because CP patient should brush with a desen- within 15-45 minutes without has a long activity time, it takes fewer sitizing toothpaste to further reduce bubbles) creates an excellent fitting nights to reach the same shade as HP the chance of sensitivity. non-scalloped, no reservoir tray for worn during the day. Conversely, HP Because bleaching materi- 10 percent CP. worn during the day will take more als penetrate the tooth and days of less wear time to equal the Tooth sensitivity is a result of 11 release oxygen, the bond nighttime bleaching with CP. the easy passage of peroxide strengths of composite to enamel are 8 through intact enamel and reduced by 50 percent if bonding is The pH to get tooth decay dentin to the pulp in five to 15 on dentin is below 6.8 and in performed immediately after bleach- minutes. This easy passage changes 5 enamel is below 5.5. Because ing. The dentist should wait two the color of the dentin as well as CP has urea, the pH of the mouth weeks after bleaching for the oxygen the enamel. Sensitivity is a transient and in the tray is elevated above 8 to dissipate before initiating bonding pulpitis, and the higher the concen- within five minutes of insertion such procedures. tration, the greater the sensitivity. that patients cannot get tooth decay The oxygen released during while wearing the bleaching tray with In addition to a proper fitting bleaching also affects the CP. Hence CP in a tray may be used tray and low concentration 12 shade of the tooth, so the for caries control when fluoride in a 9 of CP, the best treatment for patient should not be bleaching for tray is not working. HP has a pH of sensitivity involves the tray applica- two weeks prior to a shade being 5, so does not favor tooth protection tion of 5 percent potassium nitrate taken for a crown or composite. for long-term wear. for 10 to 30 minutes prior or after Since some patients may be using bleaching. Potassium nitrate is found Different tray designs are im- over-the-counter products unknown in most desensitizing toothpastes in portant for different products, to the dental office, it is important the U.S. Professional products are 6 different concentrations and that the receptionist question the also available, as well as bleaching different patients. Ten percent CP patient before scheduling an appoint- products, which contain potassium was originally designed to treat the ment that involves bonding or shade nitrate. gingivae as an oral antiseptic (Glyox- matching. Bleaching should not Restorations will not change be started immediately color from any type of ! ? 10 after a prophylaxis. Before 13 bleaching. While the surface TIME FOR A SOCIAL MEDIA initiating bleaching and to reduce will be cleaned, which may result in a CHECKUP? page 10 sensitivity issues, it is best to wait more favorable-appearing restoration, two weeks, during which time the 6HH%/($&+,1*SDJH

DentalPracticeSuccess SPRING 2016 BLEACHING Continued from page 6 the color is the same. Patients need to be informed of the cost of replacing unaesthetic restorations as a separate fee from the bleaching fee. A single dark tooth is best treated with a single tooth 14 bleaching tray rather than a full-mouth tray. This allows the single tooth to reach its maximum whitening before changes are attempted on the adjacent teeth. A single-tooth tray is fabricated by taking a full mouth tray extended further onto the tissue, and removing the tooth molds so that the bleaching material only contacts the single dark 7 tooth.

hile there is much more infor- Wmation about how to do the thing right with bleaching, these points provide a starting point for good quality patient care. )

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6HH0$5.(7%8==SDJH DentalPracticeSuccess SPRING 2016 Originally published in: Haywood V. Tooth whitening is not always tooth bleaching. Inside Dentistry. 2018;14(2):80. Perspective Copyright © 2018 to AEGIS Publications, LLC. All rights reserved. Used with permission of the publisher.

Patient education helps eliminate confusion regarding treatment options Tooth Whitening Is Not Always Tooth Bleaching

hroughout history, dentists have provided many ser- approved the first “whitening toothpaste” in 1999, the company had vices that change the color of their patients’ teeth. The to state on the package what the toothpaste was capable of doing. The oldest bleaching techniques date back to the 1800s label on this whitening toothpaste stated that it “polishes away stains,” and were performed in the dental office.T oday, the but also noted that it “is not bleaching.” Today, many toothpastes are most popular bleaching technique involves the use of being sold as “whitening” toothpastes. A close look at the product bro- trays made in the dental office for at-home wear. When chure of one of the popular whitening toothpastes reveals that the the first article on this tray technique was written in toothpaste “does not change the color of the teeth, but removes surface 1989, the technique was called “Nightguard Vital Bleaching.” As this stains.” However, this does not appear until the second page. Because Ttechnique gained popularity in the profession and around the country, manufacturers have deemphasized this fact, some consumers may dentists became concerned that when discussing “bleaching,” a tech- believe that whitening toothpaste is an equally effective alternative nique that relied on the patient applying a material in the tray at home, to bleaching treatments. There has been little research conducted on the use of the term “bleach” might lead some patients to use laundry the many OTC whitening toothpaste products without peroxides, but bleach (ie, sodium hypochlorite) in an attempt to change the color of what has been done has demonstrated that there is no inherent color their teeth. Therefore, to reduce the potential for patients to become change in the teeth, only the removal of surface stains. confused and possibly cause harm to themselves, the profession shifted The challenge with using the scientific term “whitening,” which its terminology to the word “whitening,” which sounded both more pro- is the measurement used by colorimeters and other scientific color fessional and less dangerous. In ad- measuring instruments, is that the term dition, because color measurement does not represent what is occurring instruments are used to measure during “bleaching” treatment. Whether whiteness values, the term “whiten- you remove black surface stains from a ing” has a more scientific basis. tooth, paint a tooth white on the surface, As the esthetic aspect of the den- or change the internal color of a tooth tal profession has evolved, there has by bleaching the dentin, the instrument been a proliferation of over-the- still records that the tooth is “whiter.” counter (OTC) products and tech- However, two of these processes only niques that claim to perform “whit- result in surface color changes, whereas ening.” However, in this evolution the other achieves a true internal tooth to a broader group of products and color change. techniques, the definitions of the Dentists need to educate their pa- terms relating to tooth color change tients that in general marketing terms, have diverged into two meanings: “whitening” products only remove sur- the term “whitening” now primar- face stains, but “bleaching” treatment ily refers to “the removal of extrin- changes the internal color of the tooth. sic stains from the tooth,” whereas Because there is some crossover with “bleaching” refers to “changing the in- Van B. Haywood, DMD a few effective TO C products, this will herent color of the tooth.” Bleaching not totally remove the confusion, but in produces a whitening effect, but in a most circumstances, patients will better different manner than products that Bleaching produces a understand what type of treatment they merely remove surface stains. are seeking and use their finances appropriately. Unfortunately, this differentiation between whitening effect, but in the meaning of “bleaching” and “whitening” a different manner than About the Author has caused some patients to confuse the OTC products that merely Van B. Haywood, DMD, is a professor in the products sold for “whitening” teeth with the Department of Restorative Sciences at the “bleaching” treatments that a dentist pro- remove surface stains. Dental College of Georgia at Augusta University vides. When the American Dental Association in Augusta, Georgia.

80 inside dentistry | February 2018 | www.insidedentistry.net Originally published in: Haywood V. Sword R. Bleaching Tetracycline- Inside Stained Teeth. Inside Dentistry. 2018;14(1). Copyright © 2018 to AEGIS restorative Publications, LLC. All rights reserved. Used with permission of the publisher.

peer-reviewed

Bleaching Tetracycline-Stained Teeth Considerations and recommendations for treatment Van B. Haywood, DMD | Rhoda J. Sword, DMD

n order to understand how to weeks with an average time of about 2 weeks.2 When bleaching treatment is initiated successfully bleach tetracycline- Comparatively, tetracycline-stained teeth can for tetracycline-stained teeth, a slight color stained teeth, one must first un- take 2 to 12 months or longer to bleach using change may occur during the first few days, derstand the basics of bleaching the same method.3 Although they do not nec- followed by no observable change for a month normal teeth. When considering essarily become “white,” the average time for or so of treatment. After approximately 1 to 2 bleaching, most dentists choose tetracycline-stained teeth to lighten is 3 to 4 months, the teeth will begin to lighten in the the most cost-effective, safest, and months (Figure 1 and Figure 2). The final out- same manner as normal teeth, progressing efficacious technique for both the dental of- come of bleaching tetracycline-stained teeth until they reach their maximum whiteness Ifice and the patient, which is generally recog- depends on their initial color and the consis- potential (Figure 5 and Figure 6). Although nized to be overnight tray bleaching using a tency of the color. Tetracycline is available the average treatment requires 3 to 4 months 10% carbamide peroxide bleaching agent—the in several analogues, which induce different of nightly bleaching with 10% carbamide most researched ADA approved bleaching ma- colors in the teeth. Gray discolorations are peroxide, reaching the maximum whiteness terial.1 In bleaching cases involving tetracy- the hardest to bleach, whereas brown and yel- could take as long as 15 months, depending cline-stained teeth, the extended time required low discolorations respond better. All teeth on the initial color and location of the tetra- for the teeth to change color makes choosing will lighten with bleaching; it is the extent to cycline staining. To ensure that the lightest the appropriate bleaching material and tech- which they will lighten and the uniformity shade possible is achieved, before terminat- nique even more important in terms of both that is unpredictable (Figure 3 and Figure 4). ing treatment, the patient should continue cost and safety. When addressing patients, the When bleaching treatment is initiated for bleaching for an entire month despite no word “bleaching” should be used instead of normal teeth, there may be minimal color discernible color change. “whitening.” Although many over-the-counter change for a day or two, then the teeth begin products claim that they can produce “whiten- to significantly lighten.T he teeth will con- The Importance of the ing” that rivals dentist treatments, “whitening” tinue to lighten until they reach an endpoint Bleaching Examination removes surface stains only, whereas “bleach- or plateau, which is determined by their com- Prior to using any bleaching technique, a ing” changes the inherent color of the teeth. position, not the product or technique. This proper examination and analysis of the smile The following article compares and contrasts contributes to the unpredictable nature of should be conducted.5 In addition to the smile tray-bleaching techniques for normal teeth bleaching. Once the teeth reach their maxi- itself, this evaluation should include the entire with those for tetracycline-stained teeth. mum whiteness, any further treatment or use face and account for the sclera of the eyes. The of different products/concentrations will fail examination should evaluate the extent of the How Teeth Respond to Bleaching to improve that shade. Teeth look the best teeth visible in the full smile because the gin- Every patient’s teeth respond differently to when they match the color of the sclera of gival areas of teeth do not bleach as well as the bleaching, both in the level of bleaching that the eyes, which is the desired endpoint for incisal portion (Figure 7 and Figure 8). This they obtain and how quickly that bleaching bleaching.4 However, because the final shade difference in tooth response exists because the occurs. Depending on the final shade desired, is unpredictable, promising achievement of tooth is thicker at the gingiva—with less enam- overnight tray bleaching of normal discol- a super-light shade can result in patient dis- el and more dentin—and the composition of ored teeth takes approximately 3 days to 6 satisfaction with the treatment. the dentin varies from the incisal to the root tip. With tetracycline-stained teeth, the gingival area is even more difficult to bleach. This is Van B. Haywood, DMD RHODA J. Sword, DMD because the tooth color comes primarily from Professor Associate Professor Dental College of Georgia Dental College of Georgia the dentin where the tetracycline molecule is Augusta University Augusta University more tightly bound (Figure 9 and Figure 10). Augusta, Georgia Augusta, Georgia When planning to bleach normal teeth, identification of a “gummy smile” is important because whiter teeth will make it more noticeable. Periodontal therapy for altered

38 inside dentistry | January 2018 | www.insidedentistry.net Restorative

will accentuate any less-than-ideal areas (Figure 11 and Figure 12). As with normal teeth, tetracycline-stained teeth should be examined for existing decay. Because the decay process is halted during bleaching with 10% carbamide peroxide, small non-sensitive caries do not have to be restored prior to treatment.6 However, if a deep or fig. 1 fig. 2 sensitive lesion is detected, a protective restoration using a resin-modified glass ionomer (RMGI) can be placed prior to initiating bleaching. Because predicting the final bleaching color outcome is impossible, the shade se- lection for the RMGI must be estimated. After bleaching is complete, if the RMGI no longer matches or has the desired surface gloss, its surface can be removed, leaving the deeper fig. 3 fig. 4 portion as a base. Then a composite resin that matches the shade of the bleached teeth can be bonded to the RMGI and surrounding enamel to achieve better esthetics.

Sensitivity during Bleaching All patients who are considering bleaching treatment should be evaluated for a history of sensitivity. Those with existing sensitivity issues are more likely to experience increased fig. 5 fig. 6 sensitivity during bleaching. Sensitivity during bleaching treatment results from the easy (1.) Preoperative tetracycline-stained teeth to be bleached nightly with 10% carbamide peroxide in a non-scalloped, no-reservoir tray. (2.) Overnight bleaching of one arch for 3 months to passage of the peroxide through the intact 4 months with 10% carbamide peroxide shows improvement, but not as significant as normal enamel and dentin and into the pulp, which teeth would demonstrate. (3.) Preoperative tetracycline staining in a bruxism patient often occurs in 5 to 15 minutes.7 Bleaching sensitiv- requires several trays for extended treatment. (4.) Posttreatment with 10% carbamide peroxide, teeth are lighter, but not white. One arch treatment improves compliance and helps demon- ity is a transient pulpitis resulting from this strate effectiveness.(5.) Moderately tetracycline-stained teeth that demonstrate uniform discol- easy passage, and higher concentrations of oration without severe gingival discoloration. (6.) Several months of overnight treatment with bleaching materials will result in greater sen- 10% carbamide peroxide yields a reasonable outcome, which greatly pleased the patient. sitivity.8 In addition, sensitivity can be caused by occlusal problems related to the tray. passive eruption may be indicated prior to restorations will remain the same. Therefore, Beyond using a low concentration of carb- bleaching to expose more of the teeth and if a restoration matches the existing color of amide peroxide and a proper-fitting tray, the eliminate the excessive gingival display, which the tooth, it may become unesthetic after addition of a 10 to 30 minute tray application of can reduce the need for bleaching. In order to bleaching and need to be replaced. Patients 5% potassium nitrate prior to or after bleaching appear normal, most teeth should be at least must clearly understand the financial im- treatment can help reduce associated sensitiv- 10 mm in length. The presence of a gummy plications of replacing unesthetic, tooth- ity.9 Potassium nitrate is found in most desen- smile may be less of a problem when planning colored restorations for an additional fee, sitizing toothpastes in the United States, but to bleach tetracycline-stained teeth. Because because that cost may present an obstacle is less used in other countries. With various their gingival areas are often darker and do to proceeding with bleaching. professional products available for dispensing not respond as well, tetracycline-stained teeth Periodontal conditions and gingival re- potassium nitrate, it can be applied by brushing will not create the same sharp contrast with cession should be evaluated during smile with a toothpaste, using it in the tray instead of the gingiva that is observed in a gummy smile analysis because exposed roots do not bleach. the bleaching material, or incorporating it into with lighter teeth. T etracycline-stained teeth are even darker at the bleaching material. When applied using the Existing restorations revealed in a full the gingival than normal teeth, so the expec- tray, a 5% potassium nitrate toothpaste worn smile should be evaluated for visibility and tations of these patients should be adjusted for 10 to 30 minutes will successfully reduce criticality of color because they will not to a less-than-ideal outcome. In addition, the sensitivity in more than 90% of bleaching pa- lighten with bleaching, regardless of the ma- smile analysis for both types of teeth should tients. For patients with a history of sensitivity, terial. Some surface stain removal may oc- include an evaluation for gingival disharmo- brushing with a desensitizing toothpaste con- cur on composites, but the basic color of the ny because lightening teeth with bleaching taining 5% potassium nitrate for 2 weeks prior

40 inside dentistry | January 2018 | www.insidedentistry.net to beginning bleaching treatment can significantly reduce bleaching sensitivity.10 Sensitivity generally occurs during the first 2 weeks of bleaching treatment. Although the tetracycline-stained patient will require bleaching treatment that lasts for many months, the sensitivity does not usually become progressively worse. To further reduce fig. 7 fig. 8 sensitivity issues, practitioners should wait 2 weeks after a prophylaxis before initiating bleaching, during which time the patient can brush with a desensitizing toothpaste.

Screening Radiographs Before the initiation of bleaching treatment, a screening radiograph should be taken of the anterior teeth and any individual dark teeth to determine the cause of their discoloration. fig. 9 fig. 10 Oftentimes, an abscessed tooth or internal or external resorption fails to exhibit any associated signs or symptoms other than tooth discoloration. In tetracycline-stained teeth, these color variances are more difficult to rec- ognize. Additionally, calcific metamorphosis, in which the pulp chamber is fully or partially obliterated by the deposition of secondary dentin, can cause a tooth to appear darker. fig. 11 fig. 12 The screening radiograph can also be use- ful in determining the presence of any inter- (7.) Tetracycline discoloration is not located at the difficult gingival area in this patient, which im- proximal caries or periapical cysts or tumors proves the prognosis. (8.) Four months of nightly bleaching yields an excellent result due to the that could be contributing to the darkened type and location of the tetracycline staining. (9.) Tetracycline discoloration at the gingival area appearance of a tooth or teeth. is less predictable, especially with multiple analogs causing different discolorations.(10.) Bleach- ing yields improvement, but not much change at the gingival area, even with use of a non- scalloped tray. (11.) Moderately tetracycline-stained teeth with exposed root surfaces require Bleaching Materials informing the patient of the prognosis of the exposed root. (12.) Six months of nightly bleaching Different patient instructions are required with 10% carbamide peroxide lightens the teeth, but the root surfaces remain discolored. for each of the two most used bleaching materials: carbamide peroxide and hydrogen A pH level below 6.8 is necessary for tooth Therefore, when planning to use a 10% carb- peroxide. Carbamide peroxide is composed decay to occur in dentin, and a pH level be- amide peroxide bleaching material, trays can of hydrogen peroxide and urea. Because it low 5.5 is necessary for it to occur in enamel. be made that extend 1 to 2 mm onto the gin- is active for 6 to 10 hours, carbamide perox- Because carbamide peroxide has urea, it el- gival tissue for a more comfortable fit and a ide is best used in overnight tray bleaching.11 evates the pH level of the mouth above 8.0, better seal to retain the material. The gingival Hydrogen peroxide is only active for 30 to significantly reducing patients’ ability to de- health of patients involved in bleaching re- 60 minutes, so it is more appropriate for use velop tooth decay during bleaching treatments. search projects using this concentration and during the day. A 10% carbamide peroxide Hydrogen peroxide has a pH of 5, so it does tray type has been shown to improve during product is comparable to a 3.5% hydrogen not favor tooth protection. Because of the long- bleaching. The use of carbamide peroxide peroxide product. Because carbamide per- term tray wear necessary in the treatment of concentrations higher than 10% requires scal- oxide has a longer activity time, it requires tetracycline-stained teeth, the use of 10% carb- loping the tray so that the material does not less treatments to reach the same shade amide peroxide overnight is recommended. come in contact with the gingival tissue and when compared with the use of hydrogen potentially cause a burn. For long-term wear peroxide during the day. For normal teeth, Tray Fabrication to treat tetracycline-stained teeth, the non- patient preference and lifestyle can deter- The bleaching tray design selected should scalloped tray with 10% carbamide peroxide mine the most appropriate material and wear be informed by the product to be used, its provides the most efficient bleaching possible time. However, for tetracycline-stained teeth, concentration, and the specific needs of the with the least gingival or tooth sensitivity. overnight tray bleaching with 10% carbamide patient. Products containing 10% carbamide In tray fabrication, spacers or reservoirs peroxide is the most time-efficient and -re peroxide were originally designed to treat the are not needed to bleach teeth; they are de- sults in a high rate of patient compliance. gingivae as an oral antiseptic (eg, Gly-Oxide®). signed to account for tight or ill-fitting trays.

www.insidedentistry.net | January 2018 | inside dentistry 41 Restorative

(13.) Porcelain ve- follow-up appointment, this form can be used neers were placed over tetracycline- by the dentist to help determine a fair cost for stained teeth the patient, including the amount of material prior to attempting needed for another month of treatment and bleaching, which often requires more an additional office visit.T o further reduce opaque veneers. the cost, the dentist should use a company (14.) Nightly bleach- that offers refills to sell to patients instead ing with 10% carbamide peroxide for of full kits. Because they can potentially save 4 months lightens money, patients tend to become very efficient the teeth, which with the bleaching material. This “pay as you can change the ap- parent shade of the go” approach benefits both the patient and veneers if they are the dentist. The patient can anticipate the fig. 13 not too opaque. monthly cost, and the dentist does not lose money from unanticipated extended treatment times. At each appointment, the dentist and patient can determine if another month of treatment is needed or if it is time to begin bleaching the mandibular arch.

Single Arch Treatment The dental practice needs to offer a single arch fee. The best way to maximize patient compliance and compare progress from the baseline shade is to treat only one arch at a time. In addition, patients can become discouraged from initiating treatment by a higher fee fig. 14 that includes both arches and may have other reasons for wanting to bleach the maxillary A proper alginate impression (ie, the material products unknown to the dental office, it is arch only. In bleaching research projects per- is allowed to set properly in the tray before important that the receptionist also question formed free of charge to the participants, sur- use, held in the patient’s mouth for the ap- them about any of these products that they prisingly, some patients choose not to bleach propriate manufacturer recommended time, may be using before scheduling an appoint- the mandibular arch—even at no cost. The and used to pour the model within 15 minutes ment that involves bonding or shade matching. option of wearing only one tray has several to 45 minutes without bubbles) can be used other advantages. Because there is only one to create an excellent fitting, non-scalloped, Fees for Extended thickness of material between the teeth, this no-reservoir tray for 10% carbamide perox- Bleaching Treatments approach minimizes the impact of tray bleach- ide bleaching. Not using reservoirs both con- The non-specific and longer treatment times ing on occlusion, which can reduce mechanical serves the amount of bleaching material used required to bleach tetracycline-stained teeth tooth sensitivity and eliminate potential joint and increases the comfort to the patient, es- create a unique challenge for the practitioner problems. And because fewer teeth are being pecially during the extended bleaching times concerning fees. If quoted a price for the full treated simultaneously, overall tooth sensitivi- required to treat tetracycline-stained teeth. treatment time, the potential bleaching pa- ty can be reduced as well. Single arch bleaching tient could be discouraged from proceeding treatment is especially indicated in long-term Composite Bonding with the treatment. One successful model in- treatment situations, such as for tetracycline Because bleaching materials penetrate the volves charging a reasonable initial bleaching staining, because patients can otherwise lose teeth and release oxygen, when bonding is fee for the maxillary arch, while educating the their reference for how dark their teeth were performed immediately after bleaching, the patient that any subsequent treatment and prior to treatment and become dissatisfied that bond strength between the composite and the material refill costs will depend on the length limited progress is being made. Using a single enamel is reduced by approximately 50%.12 of the bleaching process. Nationally, one arch arch approach provides many advantages, in- Therefore, dentists should avoid initiating of at-home bleaching averages around $285, cluding reduced impact on occlusion, reduced bonding procedures until 2 weeks after bleach- which includes the examination, the radio- overall sensitivity, and most importantly, in- ing treatment to give the oxygen time to dis- graph, the tray, and the bleaching material. creased patient compliance and satisfaction. sipate. The oxygen released during bleaching A typical bleaching kit will treat one arch for also affects the shade of the teeth, so patients roughly 4 weeks, and a form can be used by Patient Compliance should not bleach for 2 weeks prior to a shade patients to keep track of how quickly they Maintaining patient compliance for 2 to 6 being taken for a crown or composite. Because are using the syringes as well as to record any months of at-home bleaching treatment for some patients may be using over-the-counter color changes or sensitivity. At the 1-month, tetracycline-stained teeth may seem daunting

42 inside dentistry | January 2018 | www.insidedentistry.net Restorative to the dentist. However, with careful treatment presentation and pa- esthetics by providing lighter teeth as a starting point. Alternatively, tient understanding of the benefits, it can be achieved. Much like ad- teeth can be bleached from the lingual after veneer placement (Figure justing to a bruxism splint or an anti-snoring device, with nightly wear, 13 and Figure 14).13 In cases involving tetracycline-stained teeth, when patients can become accustomed to the use of a whitening tray. The use bleaching treatment is attempted prior to recommending veneers, of 10% carbamide peroxide for long-term wear is ideal for a number of patients can be confident that the most conservative treatment plan reasons. Compliance is better with overnight tray use, and the patient was used to achieve the most esthetic result. gets the greatest benefit per application due to its longer activity time, which reduces cost. For example, when using carbamide peroxide, Conclusion approximately 50% of the peroxide is depleted within 1 to 2 hours. Although the tooth discoloring effects associated with tetracycline in- However, the remaining material will continue to release peroxide for gestion in children have been recognized in the medical field for some another 2 to 6 hours. Therefore, if the patient only bleached for 2 hours time, tooth staining associated with adult ingestion of tetracycline before removing the tray, he or she would be discarding half of the analogs (eg, minocycline for acne treatment) also has been reported.14 active material, greatly reducing the efficiency of the individual treat- Because of the drug’s continued use to treat acne and other infec- ment and unnecessarily increasing the cost of the bleaching process. tions, such as Rocky Mountain spotted fever, tetracycline staining will continue to occur. Due to its financially and clinically conservative Bleaching vs Veneers approach, bleaching should be the initial treatment for patients with Several factors should be considered when choosing whether or not to tetracycline-stained teeth.15 Whether the case involves tetracycline- bleach tetracycline-stained teeth. Because the teeth lighten from the stained teeth or normal teeth, the most effective, cost-efficient, and incisal to the gingival, the location of the darkened areas will have an safest bleaching technique is at-home, overnight bleaching with 10% impact on the final result.T eeth with the darkest discoloration at the carbamide peroxide in a non-scalloped, no-reservoir tray. cementoenamel junction, especially dark, blue-gray areas, have the poorest prognosis for full lightening, whereas teeth with discoloration References in the incisal third have the best prognosis. Teeth that are not able 1. Christensen GJ. Bleaching teeth—which way is best? J Esthet Restor Dent. to be fully bleached at the gingival third may be good candidates for 2003;15(3):137-139. porcelain veneers. Bleaching prior to veneer preparation can help de- 2. Haywood VB. The “bottom line” on bleaching 2008. Inside Dent. 2008;4(2):82-89. termine if veneers are necessary, and when they are, it can better their 3. Haywood VB, Leonard RH, Dickinson GL. Efficacy of six months of nightguard vital bleaching of tetracycline-stained teeth. J Esthet Dent. 1997;9(1):13-19. 4. Mrazek B. “Don’t bleach until you see the white of their eyes.” Compend Contin Educ Dent. 2004;25(6):472-476. 5. Haywood VB. Pre-bleaching examination vital for optimum whitening. Compend Contin Educ Dent. 2012;33(1):72-73. 6. Bentley CD, Leonard RH, Crawford JJ. Effectof whitening agents containing carbamide peroxide on cariogenic bacteria. J Esthet Dent. 2000;12(1):33-37. 7. Cooper JS, Bokmeyer TJ, Bowles WH. Penetration of the pulp chamber by carbamide peroxide bleaching agents. J Endod. 1992;18(7):315-317. 8. Matis BA, Wang Y, Jiang T, Eckert GJ. Extended at-home bleaching of tetracycline- stained teeth with concentrations of carbamide peroxide. Quintessence Int. 2002; 33(9):645-655. 9. Haywood VB, Caughman WF, Frazier KB, Myers ML. Tray delivery of potassium nitrate–fluoride to reduce bleaching sensitivity.Quintessence Int. 2001;32 (2):105-109. 10. Browning WD. Haywood VB. Hughes N, Cordero R. Prebrushing with a potassium nitrate dentifrice to reduce tooth sensitivity during bleaching evaluated in a practice-based setting. Compend Contin Educ Dent. 2010;31(3):220-225. 11. Matis BA, Cochran MA, Eckert G. Review of the effectiveness of various tooth whitening systems. Oper Dent. 2009;34(2):230-235. 12. Da Silva Machado J, Candido MS, Sundfeld RH, De Alexandre RS, Cardoso JD, Sundefeld ML. The influence of time interval between bleaching and enamel bonding. J Esthet Restor Dent. 2007;19(2):111-118. 13. Haywood VB, Parker MH. Nightguard vital bleaching beneath existing porcelain veneers: a case report. Quintessence Int. 1999;30(11):743-747. 14. Cheek CC, Heymann HO. Dental and oral discolorations associated with minocycline and other tetracycline analogs. J Esthet Dent. 1999;11(1):43-48. 15. Leonard RH, Haywood VB, Caplan DJ, Tart ND. Nightguard vital bleaching of tetracycline-stained teeth 90 months post-treatment. J Esthet Restor Dent. 2003; 15(3):142-153. 44 inside dentistry | January 2018 | www.insidedentistry.net Originally published in: Haywood VB, Delash J. Determining Appropriate Fees for Tooth Bleaching. Inside Dentistry. Inside 2019;15(6): 34-42. Copyright © 2019 to AEGIS Publications, restorative LLC. All rights reserved. Used with permission of the publisher. peer-reviewed

Determining Appropriate Fees for Tooth Bleaching Tips for approaching treatment and coding it in a cost-efficient manner Van B. Haywood, DMD | Jacqueline Delash, DMD, MPH

etermining appropriate 50% of patients who bleached their top arch chamber or perform an endodontic therapy to fees for tooth bleaching chose not to bleach their bottom arch, even obtain internal access. A vital single tooth can in a dental office should when it was offered at no cost and they were be bleached just as easily from the “outside take into account several without previous bleaching problems. Some in” as from the “inside out.” The bleaching considerations, which are patients have stated that because no one sees code for a single dark tooth tray is the same based upon the diagnosis their bottom teeth, they simply have no fur- as a “per-arch” full tray (ie, D9975). The dif- of the cause of discolor- ther interest in pursuing bleaching treatment. ference is in the tray fabrication, which only ation and the patient’s concerns. The national Therefore, approximately 50% of patients allows the bleaching material to contact the Daverage cost of tray bleaching is between $260 who are interested and willing to pay for top- single dark tooth without changing the shade and $320 per arch, which includes the exami- arch bleaching find bleaching their bottom of the adjacent teeth (Figure 2). This allows nation, screening radiographs, impressions, arch to be an unnecessary investment in time the opportunity for the single dark tooth to trays, and other needed materials.1 Tooth and money. In addition, bleaching one arch either match the color of the adjacent teeth or “bleaching” materials are generally different at a time can improve patient compliance become lighter than the adjacent unbleached from tooth “whitening” products that are because the color contrast between arches teeth. In the latter case, an additional full tray marketed as toothpaste and other over-the- is visually evident (Figure 1). Moreover, one- is fabricated on the same cast, and the adjacent counter dentifrices. “Whitening” products arch bleaching helps with the reduction of teeth are bleached to match the new shade. generally only remove the stains from the ex- generalized sensitivity because there are less Depending on the approach to treatment, ternal surfaces of the teeth, whereas “bleach- teeth involved, and it helps to avoid occlusal a single, dark endodontically-treated tooth ing” products penetrate deep within the tooth issues because only a single tray is worn dur- presents several options for the fees and structure, changing the internal color of the ing the treatment. Lastly, a “one-arch” fee is codes. A single dark tooth that has received tooth, which resides in the dentin.2,3 When all that is required if one arch is a denture that endodontic therapy can be bleached from the offering tray bleaching to patients, consider opposes a patient’s natural teeth. Therefore, inside using the “walking bleach” technique.7 the following tips to help determine the most dental offices should offer a one-arch fee to In this technique, the inside of the pulp cham- appropriate treatment and the most cost-ef- patients as a viable treatment plan option. ber is cleaned of pulp debris, the gutta-percha fective way to code for the treatment rendered. is removed to 2 mm below the cementoenam- Single Dark Tooth Bleaching el junction, and a barrier (ie glass ionomer) is One Arch at a Time A single dark tooth that is contraindicated placed over the gutta-percha. Next, a bleach- The American Dental Association’s (ADA) for root canal therapy can be bleached exter- ing medicament (ie hydrogen peroxide, sodi- code for external bleaching for home ap- nally using a “single-tooth” bleaching tray.5,6 um perborate, carbamide peroxide) is placed plication is D9975, which is a “per-arch” Because peroxide passes through intact enam- into the pulp chamber and the endodontic treatment.4 Surprisingly, the results of early el and dentin and gets to the pulp in 5 to 15 access is temporarily sealed. The “internal” bleaching research indicated that almost minutes, it is unnecessary to open the pulp bleaching material must be changed weekly, from one to six times, depending on the desired tooth color. The ADA code for “internal V an B. Haywood, DMD Jacqueline Delash, bleaching per tooth” is D9974. However, this Professor DMD, MPH Department of Restorative Sciences Instructor process can lead to multiple dental visits and Augusta University Department of Restorative Sciences become time-consuming for both the patient Dental College of Georgia Augusta University and the provider. Because the process of in- Augusta, Georgia Dental College of Georgia ternal bleaching can take from one to six vis- Augusta, Georgia its, the amount of “meet, greet, and seat” time for the patient, as well as the treatment and

34 inside dentistry | June 2019 | www.insidedentistry.net Inside | Restorative

The dentist should consider selecting “single- tooth internal bleaching” (ie, D9974) for the code and fee because this treatment requires the most chairtime, and then include the cost of making the single-tooth external bleaching tray as a part of that fee without using a separate code. This approach is more time-efficient and profitable for the office than performing internal bleaching only. After the single-tooth bleaching is completed, which may take 8 to 10 weeks, wait 2 weeks for the shade to sta- bilize and then restore the access opening with a composite in a matching shade. If the single tooth does not fully bleach to match the fig. 1 adjacent teeth, then a lighter-shade composite should be used. Sometimes, a stark white, opaque composite material is placed into the most apical third of the access, followed by a matching shade composite in the anatomical area to close the orifice.T his composite restoration requires a different code (ie, D2330) and an additional fee. In the case of a single dark tooth that was fig. 2 fig. 3 previously endodontically treated but is ad- equately sealed with a composite, there is no (1.) Bleaching only one arch demonstrates the change to the patient when the bleached maxil- need to reenter the pulp chamber in order to lary arch is compared to the unbleached mandibular arch. (2.) A “single-tooth” bleaching tray bleach if the cleanliness of the pulp chamber allows the bleaching of one tooth without changing the color of the adjacent teeth until the final can be verified via a radiograph.T he normal, shade of the single tooth is determined. (3.) The inside of an endodontically-treated tooth must be opened sufficiently to remove pulp debris and any material that is causing discoloration.(4.) “per-arch” bleaching tray code (ie, D9975) and A pipe smoker of several years has intrinsic and extrinsic staining, which is very difficult to re- fee should be applied regardless of whether move. (5.) Three months of nightly bleaching using 10% carbamide peroxide in a custom-fitted, non-scalloped, no-reservoir tray successfully removed the nicotine staining. Figures 1, 4, and a single-tooth bleaching tray or full-arch 5 were previously published in Haywood, VB. Tooth Whitening: Indications and outcomes of bleaching tray is used to bleach the tooth. Nightguard Vital Bleaching. Chicago, IL: Quintessence; 2007 and reproduced with permission. Significant Extrinsic and Intrinsic Staining The extended treatment of nicotine- and tetracycline-stained teeth requires an approach involving a modified fee.N icotine-stained teeth (Figure 4) require 1 to 3 months of nightly treatment with 10% carbamide peroxide to remove the soaked-in nicotine stains (Figure 5). Tetracycline-stained teeth can require 2 to 12 fig. 4 fig. 5 months of nightly treatment (ie, 3 to 4 months on average) for the bleaching material to enter cleanup time, can make it difficult to predict addition of “external” bleaching requires an the dentin and remove most of the tetracycline an appropriate fee for the process. alginate impression, cast, and tray, the time staining (Figure 6 and Figure 7). Due to these To ameliorate this concern, one approach saved by allowing the patient to continue the unpredictable treatment times, the determi- is to combine both “internal” and “external” treatment for as long as is needed at home with- nation of a fair fee for both the dental office bleaching treatment. This time-efficient -ap out scheduling weekly chairtime to access the and the patient is best achieved by creating a proach involves accessing the tooth internally tooth and change the material offsets the cost. “pay-as-you-go” process. The patient pays the to clean the pulp chamber, place the barrier, This allows the practice to be more time- and normal single-arch bleaching fee using code and add the bleaching medicament, as is done cost-efficient and allows the patient to spend D9975 and is provided with roughly enough in the walking bleach technique (Figure 3); less time traveling and visiting the office. material to bleach one arch for 1 month. During however, after this initial access, the bleaching The challenge with the dual “inside and out- this time, the patient uses a form to record their process is continued from the outside in using side” bleaching approach is choosing the best nights of treatment to determine exactly how a “single-tooth” bleaching tray. Although the procedure code and the most appropriate fee. long the initially dispensed syringes will last,

36 inside dentistry | June 2019 | www.insidedentistry.net which in turn, determines how often the patient the RMGI matches reasonably well, and the will require a refill. The fee for the extended patient is satisfied with the appearance, then treatment becomes the cost of the materials no further treatment is needed. However, if used per month plus any chairtime needed the final bleaching shade does not match the until the desired shade is reached. The dental previously placed RMGI, or the surface gloss office can charge accordingly for the purchase is insufficient, then the dentist need only re- of subsequent bleaching refill kits. Because the move the external portion of the RMGI and treatment time can vary greatly based on each bond an appropriate shade of composite, leav- patient’s situation, this method of calculating ing the remaining RMGI as a base. Although payment is fair to both the patient and to the this additional treatment provides the best dental office. It also allows flexibility for the esthetics and the safest option for deep decay patient to bleach to the point when the shade or sensitive lesions, it requires a separate fee stabilizes without further change or to the point and code for the final resin-based composite when he or she is pleased with the result, tires restoration (ie, D2332). of the procedure, or no longer wishes to spend further finances on bleaching. Thermoplastic Trays For the maxillary arch, the use of thermo- Existing Decay Considerations plastic trays10 can facilitate a reduced fee for When considering bleaching in cases involv- patients who require only minimal lightening existing decay, the treatment may require ing or who have difficulty with the process of two different codes and fees.T he final shade making impressions (Figure 14). Teenagers achieved and the rate of shade change from and young adults often have reasonably white bleaching is different for every patient.I f the teeth but may still have a desire to maximize patient is interested in bleaching and presents their tooth shade.11 As opposed to pursuing with existing decay that requires a restoration, over-the-counter products,12 it is best for the the dentist cannot reliably predict the final dentist to provide a proper examination and shade of the restoration prior to bleaching. radiographs to determine a diagnosis for any Fortunately, bleaching with 10% carbamide discoloration.13 Fabrication of a thermoplas- peroxide stops the progression of decay while tic tray can be accomplished in a few minutes the bleaching treatment is in process.8,9 With and bypasses the need for alginate impressions, most small carious lesions, the dentist can casts, and a vacuum former. Although the stan- bleach over the existing decay (Figure 8 and dard single-arch bleaching code is still used, the Figure 9), wait 2 weeks for the shade to stabi- associated fee can be reasonably reduced be- lize and the bond strengths to return to normal, cause this approach requires less chairtime, no then restore the lesion with the appropriate laboratory work, and no impression material. shade of composite. This can provide an excellent way to help some However, if the decay is deep or the tooth patients achieve their desired level of esthetics is sensitive, the caries needs to be removed without needing to charge the full fee for the prior to bleaching to avoid further pulpal in- traditional bleaching impression/cast. This ap- sult (Figure 10). In these cases, the dentist can proach works best on the maxillary arch due first place a “protective restoration” (ie, code to the tongue’s position when swallowing to D2940) with a resin-modified glass ionomer form the tray. This normal swallowing benefit (RMGI), selecting the best possible projec- is not present when attempting a mandibular tion of the final shade (Figure 11). With this thermoplastic tray, so the mandibular arch protective restoration placed, the patient will usually require a traditional impression can then bleach his or her teeth while also and tray with a different fee. Just as with tra- minimizing the concern of a pulpal insult or ditional, single-arch bleaching, completing one further progression of caries if he or she un- arch at a time is inherently less expensive and expectedly stops bleaching. If the esthetics can provide the patient with visible results to of the RMGI need improvement during the later determine whether or not bleaching the bleaching process, a thin layer of resin infil- mandibular arch is desired. trate (eg, Optiguard™ Surface Sealant, Kerr™) can be added to the surface of the restoration Orthodontic Considerations to create a glossy and natural appearance The occurrence of white spot lesions and (Figure 12 and Figure 13). Upon completion caries from improper oral hygiene during of the bleaching treatment, if the shade of orthodontic treatment can be significantly

www.insidedentistry.net | June 2019 | inside dentistry 37 Inside | Restorative reduced by utilizing bleaching materials.14 Although this approach requires adding an additional fee to that of the orthodontic treatment, the benefits of bleaching while the patient is in an orthodontic appliance can greatly reduce the need for and cost of restorative treatment after the completion of orthodontic therapy. This preventive approach is highly effective because in addition to bleaching the teeth, the bleaching material helps to cleanse the teeth and gingiva from fig. 6 fig. 7 bacteria and plaque during orthodontic treatment. Considering the ease of use, cost-effectiveness, and minimal chairtime required, thermoplastic material is ideal for making bleaching trays that fit over orthodontic brackets intraorally (Figure 15). These trays help to fend off white spot lesions and decalci- fication by elevating the intraoral pH, removing plaque, and killing some of the bacteria that cause tooth decay. As the teeth continue to shift during orthodontic treatment, new fig. 8 fig. 9 trays will need to be fabricated approximately every 2 to 3 months, which can add about $400 to $800 to the total treatment costs over a 2-year treatment period. The attraction of this approach is twofold. First, the young patients undergoing orthodontic therapy are motivated to wear the tray because they are bleaching their teeth, and second, the parents are receiving value in their investment via improved hygiene and a reduction in white spot lesions or caries, which subsequently fig. 10 fig. 11 reduces the potential need for costly future restorations that could range from $175 to $250 per tooth. Furthermore, the thermoplastic trays can be made directly over the orthodontic brackets in the mouth and can also serve as a “sports guard” to minimize bracket damage to the lips and cheeks. The only segment of orthodontics for which this treatment does not apply is when the patient is in cross-elastics. For these patients, inject- ing 10% carbamide peroxide directly onto the fig. 12 fig. 13 brackets will afford some hygienic benefits, as will using a water pick with a 1:1 ratio of water (6.) Tetracycline staining occurs deep in the dentin and is the most difficult stain to remove.(7.) and 3% hydrogen peroxide (Figure 16). In ad- Tetracycline-stained teeth after 7 months of nightly bleaching treatment with 10% carbamide dition, an over-the-counter, 10% carbamide peroxide in a non-scalloped, no-reservoir, custom tray. (8.) Patient with minimal decay that peroxide oral antiseptic supplementary prod- does not need to be restored prior to bleaching because the final shade cannot be determined in advance. (9.) After bleaching over minimal decay, the proper shade can be selected, and uct (eg, Gly-Oxide® Liquid Antiseptic Oral the tooth can be restored. (10.) A patient with extensive decay that elicits concerns regard- Cleanser, GlaxoSmithKline) can be injected ing pulpal involvement as well as the restorability of the tooth needs some type of protective directly onto the teeth and tongue for a 2- to restoration prior to the initiation of bleaching. (11.) The caries is removed, and a protective restoration is placed to allow for further bleaching without concern for the advancement of 3-minute cleaning rinse. This product is also decay if the patient stops bleaching. (12.) A provisional canine restoration made from bis-Acryl used to disinfect and deodorize bleaching does not exhibit the gloss of the adjacent fixed partial denture or teeth.(13.) Placing a compos- trays and many other appliances (eg, occlu- ite sealer provides more natural gloss while bleaching is being completed. Figures 6 and 7 were previously published in Haywood, VB. Tooth Whitening: Indications and outcomes of Night- sal guards, oral sleep appliances). Moreover, guard Vital Bleaching. Chicago, IL: Quintessence; 2007 and reproduced with permission. the manufacturer recommends placing it

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fig. 14 fig. 15

(14.) An example of a thermoplastic tray that can be softened with hot water and formed directly in the mouth without making an alginate impression and cast. (15.) Thermoplastic tray fabricated directly in the mouth and over the braces with no need to remove the arch wires. (16.) Gly-Oxide, which has a bubbling, foaming action, is injected into the brackets as an adjunct to oral hygiene procedures. (17.) Custom tray used with 10% carbamide peroxide and worn nightly for caries control in elderly patients. (18.) Patient injects 10% carbamide peroxide into an area that is difficult to clean with conventional methods. fig. 16

fig. 17 fig. 18

on toothbrushes prior to the toothpaste as which is D5986, and the appropriate code to an adjunct to improve overall oral hygiene. use for the material is for “drugs or medica- Although Gly-Oxide was the original bleach- ments dispensed in the office for home use,” ing material, it is too runny for tray bleaching which is D9630. Bleaching products contain- and does not stay on teeth for long periods; ing urea, such as carbamide peroxide, elevate therefore, thicker, more viscous materials the pH of the mouth, which stops or slows are indicated for tray use to achieve longer the process of tooth decay. This change in pH lasting benefits. occurs within 5 minutes of tray insertion,15,16 and the pH remains elevated while the trays Caries Control are in the mouth. In addition, carbamide per- One adjunct to routine caries control is the oxide has been shown to kill the bacteria that use of carbamide peroxide with custom trays. cause caries.17 Accordingly, the bleaching pro- This approach can be especially helpful in el- cess effectively removes the salivary film and derly patients with dry mouth (Figure 17) or plaque layer from the teeth, leading to envi- who experience reduced salivary flow from ronmental control and a reduction in caries. radiation therapy. Treatment to control caries The challenge associated with this approach with bleaching products should not be given to caries control is the ongoing cost of the 10% bleaching codes. The appropriate code to use carbamide peroxide. It can be supplied from for the tray would be for a “fluoride gel carrier,” the dental office in the same manner as it is

40 inside dentistry | June 2019 | www.insidedentistry.net Inside | Restorative for the extended treatment approach. Lastly, bleaching. Inside Dentistry. 2018;14(2):80. Fabrication of immediate thermoplastic whiten- the patient can pursue over-the-counter 10% 3. Haywood VB, Sword RJ. Bleaching tetracycline ing trays. Contemporary Esthetics and Restorative carbamide peroxide products for supplemen- stained teeth: considerations and recommendations Practice. 2001;5(9):84-86. tal caries control (Figure 18). for treatment. Inside Dentistry. 2018;14(1):38-44. 11. Greenwall-Cohen J, Greenwall L, Haywood V, et 4. American Dental Association. CDT-2017 Code al. Tooth whitening for the under-18-year-old patient. Conclusion on Dental Procedures and Nomenclature. Delta Br Dent J. 2018;225(1):19-26. In summary, there are many unique situations Dental Website. https://www.deltadentalco.com/ 12. Haywood VB, Boyleston E. Does “activated char- related to tooth bleaching that require differ- uploadedFiles/ProviderFeeSchedules/DDCO_Par_ coal” effectively whiten teeth?Dimensions of Dental ent approaches to treatment, and these vari- Provider_Documents/CDT%202017_Code%20 Hygiene. 2017;15(12):66. ous approaches necessitate the determination on%20Dental%20Proc_Nomenclature%20online. 13. Haywood VB. A pre-bleaching exam is vital for op- of appropriate treatment codes and related pdf. Accessed January 3, 2019. timum whitening. Inside Dentistry. 2012;8(9):66-68. fees. Bleaching is best performed by the dental 5. Haywood VB. Bleaching a retained primary tooth. 14. Haywood VB. Orthodontic caries control and office after a proper examination, radiographs, Dentistry Today. 2018;37(8):74-77. bleaching. Inside Dentistry. 2010;6(4):36-50. and a diagnosis of the cause of discoloration.18 6. Haywood VB, DiAngelis AJ. Bleaching the single 15. Leonard RH Jr, Austin SM, Haywood VB, et al. The ability to tailor the treatment to the spe- dark tooth. Inside Dentistry. 2010;6(8):42-52. Change in pH of plaque and 10% carbamide peroxide cific needs and conditions of the patient is a 7. Freccia WF, Peters DD, Lorton L, et al. An in vitro solution during nightguard vital bleaching treatment. major benefit of having the dental team super- comparison of nonvital bleaching techniques in the Quintessence Int. 1994;25(12):819-823. vising ongoing bleaching treatment. discolored tooth. J Endod. 1982;8(2):70-77. 16. Leonard RH Jr, Bentley CD, Haywood VB. Salivary 8. Haywood VB. Bleaching and caries control in el- pH changes during 10% carbamide peroxide bleach- References derly patients. Aesthetic Dentistry Today. 2007;1(4): ing. Quintessence Int. 1994;25(8):547-550. 1. American Dental Association. 2018 Survey of 42-44. 17. Bentley CD, Leonard RH, Crawford JJ. Effect of Dental Fees. ADA Center for Professional Success 9. Lazarchik DA, Haywood VB. Use of tray-applied 10 whitening agents containing carbamide peroxide on Page. https://success.ada.org/en/practice-man- percent carbamide peroxide gels for improving oral cariogenic bacteria. J Esthet Dent. 2000;12(1):33-37. agement/finances/survey-of-dental-fees. Accessed health in patients with special-care needs. J Am Dent 18. Haywood VB, Bergeron BE. Bleaching and the di- January 3, 2019. Assoc. 2010;141(6):639-646. agnosis of internal resorption. Decisions in Dentistry. 2. Haywood V. Tooth whitening is not always tooth 10. Haywood VB, Caughman WF, Frazier KB, et al. 2018;4(8):20, 22-25.

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