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What's up with Whitening? Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants. What’s Up With Whitening? An Update on Professionally Dispensed Vital Tooth Bleaching A Peer-Reviewed Publication Written by Howard E. Strassler, DMD, FADM, FAGD and Gregori M. Kurtzman, DDS, MAGD PennWell is an ADA CERP Recognized Provider Go Green, Go Online to take your course This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives does not require wearing of the tray for long periods of time. Upon completion of this course, the clinician will be able to Bleaching relapse is a reality. The article will also describe do the following: ways for patients to maintain the whiter and brighter smile 1. List the different types of vital tooth bleaching systems. that was created with vital tooth bleaching. 2. List the esthetic conditions that can be treated with vital Bleaching is usually used to lighten teeth darkened by tooth bleaching. intrinsic and/or extrinsic discoloration. In some cases normal 3. Describe the adverse reactions that have been associated tooth color can be lightened to a whiter smile for those patients with vital tooth bleaching. who want to improve their esthetic appearance. However, not 4. Describe the clinical technique for professional vital all tooth discolorations are amenable to successful treatment tooth bleaching using a tray system. with vital tooth bleaching. Before making the decision to per- 5. Describe how to manage bleaching relapse. form vital tooth bleaching, a thorough clinical examination and evaluation of the existing oral conditions must be made Abstract to establish a diagnosis. There will be times when radiographs Professionally dispensed vital tooth bleaching techniques are necessary to establish and verify a diagnosis. include a variety of concentrations of hydrogen and carb- amide peroxide, in-office techniques with and without light Diagnosis and clinical evaluation of tooth or heat enhancement, professionally dispensed whitening discolorations strips and tray bleaching. A predictable technique that does Tooth discolorations can be a result of enamel mottling, tet- not require wearing of trays for long periods of time improves racycline staining, trauma, developmental hypoplasia, caries patient compliance. Tooth whitening with the latest genera- demineralization, age-related extrinsic enamel staining, thin- tion of vital bleaching products is effective, safe and relatively ning of enamel with subsequent dentin shine-through, and long lasting. Bleaching can be maintained through the use staining of teeth due to smoking, food and beverage ingestion. of whitening toothpastes and bleaching toothpastes or with These types of tooth discolorations can modify the esthetics yearly touch-up bleaching using the patient’s custom fitted of teeth so that patients find their appearance and the appear- tray. Vital tooth bleaching is a viable, esthetic treatment for ance of their smile unacceptable. the discolored dentition. Tooth discolorations can be classified as either intrinsic (within the enamel and dentin) or extrinsic (on the surface Professionally Dispensed Vital Tooth Bleach- of the enamel). Intrinsic discolorations are deep within the ing: An Update tooth, usually a dentin discoloration. Examples of intrinsic Esthetic restorative dentistry includes many treatment mo- tooth discolorations are tetracycline staining of the teeth and dalities to change the appearance of teeth. Unfortunately, most endodontic staining. Extrinsic discolorations are superficial techniques involve the placement of restorations, which gen- and located in the enamel. Fluorosis and enamel hypoplasia erally requires some tooth preparation and the need to replace (“white spots”) are examples of extrinsic discolorations of some of these restorations over the patient’s lifetime. With the the enamel. increased knowledge and interest by patients in having the Mottled enamel, also know as enamel hypoplasia due appearance of their teeth changed with esthetic dentistry, the to fluoride or fluorosis, is caused when children ingest too more conservative techniques have gained wider acceptance. much fluoride during tooth development. This can be the Changing the appearance of teeth to improve a patient’s smile result of a child swallowing a fluoride-containing toothpaste may include modifying tooth contours, shapes, color and po- or a fluoride mouth rinse, or ingesting fluoride-containing sition. Where the modification of tooth shape, contours and vitamins when the water and other beverages being ingested position is necessary to achieve an improved esthetic result, have the minimal dose of fluoride necessary to provide enamel orthodontics and restorations may be indicated. When there protection. Fluorosis has a varied appearance depending on are no patient concerns about the appearance of the teeth and the amount of fluoride ingested.1 Mild fluorosis usually has smile other than color, the most conservative clinical tech- the appearance of white flecking or spotting of the enamel or nique is vital tooth bleaching. white opaque areas on the enamel surface. When fluorosis is Professionally dispensed vital tooth bleaching refers to moderate to severe, the enamel takes on a brownish appear- the materials used for vital bleaching that are dispensed in ance (mottling) that can be combined white opaque spots the dental office. These techniques can include a variety of or pitting defects on the enamel surfaces. In cases of severe concentrations of hydrogen and carbamide peroxide, in-of- fluorosis, the enamel has a very pitted, eroded appearance. In fice techniques with and without light or heat enhancement, addition, moderate to severe dental fluorosis can contribute to professionally dispensed whitening strips and tray bleaching. the enamel being more susceptible to wear and fracture due to This article will review the different systems, indications and the pitted and thinned edges of the teeth. contraindications for vital tooth bleaching, adverse effects, A patient with teeth that appear yellow, brown-orange or and describe a predictable technique for tray bleaching that blue-gray-brown, demonstrates the consequences of taking 2 www.ineedce.com tetracycline-based medications for the treatment of child- shine-through phenomenon in the enamel. Once the bacterial hood infections.2,3 Tetracycline staining was first described in invasion responsible for the carious lesion has penetrated into 1956.4 This intrinsic discoloration appears to be caused by the the dentin, restoration is necessary.12 binding of the tetracycline to the calcium in the enamel ma- trix during mineralization.5,6 Tetracycline discoloration can Bleaching, a treatment for also present with the clinical appearance of banded staining, the discolored dentition with the darkest staining at the gingival third of the tooth due Tooth bleaching was reported as early as 1877, but it has only to the thinness of the enamel in that area and the discoloration been in the last 30 years that the conservative treatment of the within the underlying dentin. A differential diagnosis of tet- discolored dentition with high concentrations of heated hy- racycline staining can be made by shining an ultraviolet light drogen peroxide has been accepted.13,14,15 Unfortunately, this on the teeth. If the teeth fluoresce, then the diagnosis is most use of a heated, high-concentration hydrogen peroxide has likely tetracycline staining. clinical problems and adverse reactions that include the need In recent years, other medication-induced discolorations for multiple office visits (five to seven) to attain an acceptable have been observed. Unlike the characteristic tetracycline result, tooth hypersensitivity, soft-tissue irritation due to the staining that occurs during tooth development, these discol- high-concentration hydrogen peroxide seeping under the orations appear after the teeth are fully erupted in the mouth. dental dam, and significant chair time. The staining has a bluish-gray appearance. Minocycline has Over the past 15 years, other techniques for vital tooth been implicated in the discoloration of the permanent denti- bleaching have been described. In 1989, a technique using tion after eruption of the teeth.7 an at-home mouthguard (tray) with 10% carbamide peroxide Another cause of intrinsic discoloration of vital teeth is was described as successfully whitening teeth.16 This report trauma to the tooth during enamel formation.8 If the primary was followed by the introduction of other carbamide peroxide tooth is traumatized, blood products in the soft tissue can be products. Concerns about the safety, efficacy and longevity incorporated into the mineralization of the permanent tooth of these bleaching techniques were initially expressed by the enamel matrix. These teeth have a yellow-brownish, opaque United States Food and Drug Administration and the dental appearance. Also, permanent teeth that are fully or partially profession.17,18,19 A number of reports have adequately ad- erupted when traumatized can become similarly discolored dressed these concerns and have demonstrated the safety and still maintain their vitality, or upon radiographic exami- and effectiveness of tooth whitening with peroxide prod- nation reveal an obliterated (narrowed) root
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