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A Review of Tooth Whitening Services and Agents

A Review of Tooth Whitening Services and Agents

Go Green, Go Online to Green, Online takeGo your course andagents. whitening services transient hypersensitivity. This course provides areview of ofwhiteningmost common procedures sideeffect is appearance ofteeth by addressing intrinsic stains. The Peroxide containing whitening agents enhance the tooth through pits, irregularities. fissures andsurface becomecan intrinsic by migrating to theinterior ofthe easily removed duringaprophylaxis. discoloration Extrinsic discoloration are stainsare intrinsic andextrinsic. Extrinsic counter whitening agents. The oftooth two majortypes whitening andover take-home includein-office, the of diminishing. The methodsoftooth three primary the U.S. strong andgloballyisvery andshows nosigns Utilization in oftooth whitening andservices products Abstract Expiration date: 2018 June Publication date: 2015 July Written by H.Nagelberg, Richard DDS A Peer-Reviewed Publication ToothServices Whitening A Review of Supplement to PennWellSupplement Publications (10/31/2015) Provider ID#320452. orAGDdentistry endorsement. The current term ofapproval from extends (11/1/2011)to maintenance credit. Approval doesnotimply acceptance by astate orprovincial board of program provider are accepted by theAGD forFellowship, Mastership andmembership Academy ofGeneral . The formal continuing dental education programs ofthis The PennWell Corporation isdesignated asanApproved PACE Program Provider by the “This course Board meetstheDental ofCalifornia’s requirements for 3unitsofcontinuing education.” BoardDental ofCalifornia: Provider 4527,course registration number CA#03-4527-15017 PennWell for3continuing designates educational thisactivity credits.

4. 3. 2. 1. willbeableto: participants At theconclusion ofthiseducational activity Educational Describe thedifferentDescribe oftooth staining. types agents. thepotential of Discuss benefitsandsideeffects and theirmechanismofaction. theavailableDescribe tooth whitening agents professionals. responsibilities ofdental theprimary Discuss

Objectives Registration: and improvements inoral health. data andinformation contained inreference section. The research data isextensive andprovides benefitto direct thepatient Known Benefitsand Limitations oftheData: The information presented isderived from inthiseducational activity the the mostcurrent information available from evidence baseddentistry. Integrity Statement:Scientific Information shared inthisCEcourse isdeveloped from research clinical andrepresents Statement:Image Authenticity haveThe images inthiseducational notbeenaltered. activity experienceand clinical to that develop allows theparticipant skills and expertise. inthefieldrelated beinganexpert toin theparticipant thecourse topic. Itisacombination ofmany educational courses CompletingEducational Disclaimer: asinglecontinuing education course doesnotprovide enoughinformation to result inthiseducational discussed activity.or services Heather bereached can at [email protected] HeatherCE PlannerDisclosure: Hodges, CECoordinator doesnothave aleadershiporcommercial interest withproducts fee, review thematerial, complete thecourse evaluation andobtainascore ofat least70%. Requirements Completion: for Successful To you obtain3CEcredits mustpay for thiseducational the required activity any inputinto thedevelopment ofcourse content. norwiththecommercial orshareddiscussed inthiseducational supporter. activity hashad No orthird manufacturer party Provider PennWell Disclosure: doesnothave aleadershippositionorcommercial interest inany orservices products Educational Methods: This journalandweb course isaself-instructional activity. This coursewas written for , dentalhygienists andassistants, from novice to skilled. hasbeenmadepossiblethroughThis anunrestricted educational grant activity from Ultradent. contacting PennWellcontacting inwriting. Cancellation/Refund Policy: whoisnot100% satisfied Any withthis course request can participant afullrefund by The cost ofthis CEcourse is $59.00for 3CEcredits. Dr. Nagelberg isEditorial Director, Education, Dental PennWell Publishing. Author Disclosure be reached at [email protected]. dental professionalsimpact have beyond theoral cavity. Dr. Nagelberg can internationallylectures oftopics onavariety centered onunderstandingthe Connection”. Arespected memberofthedental community, Richard column Economics inDental magazine, “GP Perio-The Oral-Systemic for several dental companies andorganizations. Richard hasamonthly board member,advisory speaker, key consultant opinionleaderandclinical ofPerioFrogz.com,co-founder company, aninformation services andan having provided in dental services Thailand, Cambodia, andCanada. He is Philadelphia for 32years. He hasinternational experience, practice Dr. insuburban general Richard Nagelberg dentistry hasbeenpracticing Author Profile

written fordentists, dental hygienists, 3 CEcredits This coursewas and assistants. Earn

© Ryanking999 | Dreamstime.com Educational Objectives “The ADA recommends that if you choose to use a - At the conclusion of this educational activity participants will ing product, you should only do so after consultation with a be able to: . This is especially important for patients with many 1. Discuss the primary responsibilities of dental fillings, crowns, and extremely dark stains. A thorough oral professionals. examination, performed by a licensed dentist, is essential to 2. Describe the available tooth whitening agents and their determine if bleaching is an appropriate course of treatment. mechanism of action. The dentist and patient together can determine the most ap- 3. Discuss the potential benefits and side effects of tooth propriate treatment. The dentist may then advise the patient whitening agents. and supervise the use of bleaching agents within the context of 4. Describe the different types of tooth staining. a comprehensive, appropriately sequenced treatment plan.”

Abstract Thorough Oral Exam and an Appropriately Utilization of tooth whitening products and services in the U.S. Sequenced Treatment Plan and globally is very strong and shows no signs of diminishing. The ADA recommends the provision of other esthetic dental The three primary methods of tooth whitening include in-of- services as well. Regarding porcelain veneers, the organization fice, take-home and over the counter whitening agents. The two states; “There’s no reason to put up with gaps in your teeth, or major types of are intrinsic and extrinsic. Ex- with teeth that are stained, badly shaped or crooked. Today a trinsic stains are easily removed during a prophylaxis. Extrinsic placed on top of your teeth can correct nature’s mistake discoloration can become intrinsic by migrating to the interior of or the results of an injury and help you have a beautiful smile.” the tooth through pits, fissures and surface irregularities. Perox- The most impactful aspect of the ADA’s whitening position ide containing whitening agents enhance the appearance of teeth statement is that use of bleaching agents are to be undertaken by addressing intrinsic stains. The most common side effect of within the context of an appropriately sequenced treatment plan. whitening procedures is transient hypersensitivity. This course Appropriate sequence clearly means prioritizing patient needs, provides a review of tooth whitening services and agents. with disease and function first, and esthetic procedures provided during or after disease management and restoration of proper func- Introduction tion. The ADA also notes the need for a thorough oral examination Esthetic dental services have developed over a relatively short by a licensed dentist to determine if tooth whitening treatment is period of time and the demand for these services is very high. appropriate for the patient. Providing veneers, porcelain crowns, Recent estimates indicate that Americans are spending over 2 tooth whitening etc. to a patient with uncontrolled periodontitis billion dollars annually on the various types of tooth whitening would be similar to a physician providing Botox® injections to a pa- products and services available. The terms whitening and bleach- tient with uncontrolled hypertension, diabetes or atherosclerosis, ing are used interchangeably by both the dental profession and among others. This is obviously the reason why the ADA cautions the lay public. It may be worthwhile to emphasize to patients that against the use of whitening services without consideration of the bleaching does not refer to the type of bleach used in the laundry. patient’s oral and overall health. Failure to examine, treatment plan Whitening agents are not drugs and as such, are not regulated by and address the highest priority dental needs prior to providing the Food and Drug Administration. It should be appreciated that cosmetic procedures would be ethically questionable. In certain not all patients who desire whiter teeth are good candidates. Oral circumstances necessary and elective procedures can be provided and systemic contraindications preclude some patients from these simultaneously, depending on the specific dental needs. If a pa- services. Patient expectations should also be addressed along with tient has a limited number of small to moderate carious lesions and the potential side effects, most notably hypersensitivity. Esthetic healthy gingiva, providing in-office whitening or impressions for procedures including tooth whitening must be considered within take-home whitening can be provided when the carious lesions are the context of the patient’s oral and general health, which are the treated. If a patient has xerostomia, the etiology should be deter- primary responsibilities of dentists, dental hygienists and other mined and the condition should be addressed with an antioxidant dental professionals. Diagnosis and management of disease is the gel or an enzymatic oral rinse, among others. first and most important priority of dental clinicians. It would be is a category unto itself. Gum disease is inappropriate to provide tooth whitening services or any other a bacterial infection, with inflammation-driven damage to the cosmetic dental procedure to a patient with periodontal disease, hard and soft tissue which must be controlled prior to under- caries or mucosal lesions, among many others. taking a cosmetic treatment plan of any kind. This may take an extended period of time. The overarching reason for addressing The ADA Position Statement on Tooth Whitening and controlling periodontal disease, high caries rate, xerostomia In April 2012 the ADA Council on Scientific Affairs adopted or any other oral pathology or condition prior to providing es- its; “Statement on the Safety and Effectiveness of Tooth Whit- thetic dental services is because the same problems will continue ening Products”. The summary of the statement is as follows: or recur after the desired cosmetic result is achieved.

2 www.ineedce.com It is completely ethical to provide tooth whitening or other Intrinsic Stains cosmetic procedures when undertaken in a properly sequenced When extrinsic stains migrate below the surface they become treatment plan. Contributory medical conditions such as diabe- intrinsic stains and can no longer be removed by mechanical tes, chronic infections, autoimmune disorders and chronic in- means. Intrinsic molecules that cause discoloration are organic flammatory conditions are addressed first. Referral to a dental pigments incorporated into enamel during tooth formation. specialist or physician may be necessary. The patient’s The visual effects of intrinsic tooth are associated with control regimen should also be thoroughly evaluated since the the absorption and reflection of light by the enamel and most common oral diseases and conditions are directly linked with the dentin playing the primary role in determining overall to the oral bacterial load. Recommendations for the appropriate tooth color. The natural off-white hue of enamel is modified biofilm control devices such as power toothbrushes, antimicro- by the yellow/brown shades of dentin, together determining bial rinses and interdental cleaning devices should be provided the normal color of an individual’s teeth. Discoloration can also not only to facilitate optimal oral and general health, but to be caused by trauma, and a number of metabolic protect the patient’s financial investment in their appearance. diseases and other systemic factors. Postnatal infections such as chicken pox, streptococcal infections and scarlet fever can Extrinsic Stains result in tooth discoloration as well. With advancing age, an The superficial or extrinsic coloration of an individual’s teeth individual’s teeth commonly take on a generalized yellow or is associated with stain that accumulates on the surface of the brown color. This occurs as a result of thinning of the enamel, teeth from food and beverages, which can seep into the cracks, thus revealing more of the darker underlying dentin. Addition- pits and flaws in the enamel. Seepage can also occur between the ally, over time, the dentin becomes darker from the formation enamel rods in some cases. Some individuals seem to be more of secondary dentin in response to restorations and normal susceptible to extrinsic staining due to enamel surface mor- physiologic processes. phology, salivary proteins, diet, usage and the efficacy of the home care. High levels of extrinsic staining are caused by Figure 3. Discoloration of central incisor from trauma polyphenolic compounds found in food and beverages such as red wine, darkly brewed tea, chocolate, coffee, grapes, pome- granate, spinach and plums, among others. Superficial stain accumulation occurs as a result of the attraction between the negatively charged salivary pellicle and the positively charged food/beverage molecules. (Figures 1, 2) Extrinsic stain is sub- stantially removed by abrasives in and prophy paste.

Figure 1. Staining from rinse

Figure 4. Discoloration from trauma

Figure 2. Extrinsic stain

www.ineedce.com 3 Figure 5. Fluorosis staining Figure 9. Staining from postnatal infection

Figure 6. Fluorosis staining Enamel is semitranslucent and the underlying dentin color and other colored substances beneath the enamel affects the overall color of the teeth. Tooth color is caused by a variety of factors including the influence of genetics, drugs and medica- tion taken by the mother while pregnant or the child during tooth development such as tetracycline. Environmental factors such as excess intake and maternal infections also influence tooth color. An individual’s genetic makeup is the primary determinant of tooth color. Some people’s teeth have a blue-gray base color, others more yellow-brown. When it comes to tooth whitening, yellow and brown base colored teeth whiten faster than blue-gray teeth. The color molecules are comprised of groups of atoms that are Figure 7. Tetracycline staining held together by bonding forces. Some of these bonding forces themselves absorb and reflect light. The absorption of light makes the object, in this case the teeth, appear darker and light reflec- tion gives the appearance of color. These absorbing and reflecting bonds are called chromophores and they are all around us. Every- thing we see, and the we observe are due to chromophores. Peroxide based whitening agents work by breaking the chromo- phore bonds, bringing out the natural whiteness of the teeth.

Mechanism of Action of Peroxide Tooth Whitening Agents Intrinsic staining is removed by chemical means, primarily dif- ferent forms of peroxide. Typically used whitening agents are or carbamide peroxide-containing whitening Figure 8. Tetracycline staining gels, liquids, strips etc. Carbamide peroxide is broken down into hydrogen peroxide and upon dissolution in water or saliva. Peroxide based bleaching products diffuse into the tooth and re- act with the color molecules. The mechanism by which peroxide compounds lightens the color of the teeth involves the chemi- cal composition of the intrinsic stain. Upon application of the

bleaching gel, hydrogen peroxide (H2O2) breaks down into H2O and a free reactive oxygen species. These hydrogen peroxide breakdown products attach to the stained portions of the teeth which have the chromophore bonds. The free reactive oxygen species break the double chromophore bonds into single bonds. The single bonded carbon atoms produce colorless molecules bringing out the natural whiteness of the teeth. (Figure 10)

4 www.ineedce.com Figure 10. Mechanism of Action: Hydrogen Peroxide (H2O2) Figure 12. Curing dam

H2O2

Free Figure 13. Application of whitening gel Generated

Carbon Double Bond

Tooth Whitening Treatments Chemical tooth whitening can be performed in-office or at home, using products dispensed in the office or over the coun- ter (OTC). Professionally provided and consumer take-home Figure 14. Completing application of whitening gel bleaching agents are supplied as pastes or gels that are used in trays, strips, rinses or paint-on liquids. The whitening agents typically used with take-home products are carbamide peroxide or hydrogen peroxide. The concentration of the whitening agent ranges between 10-35% depending on the manufacturer. The same agents are used for in-office whitening and the con- centrations can range up to 40% hydrogen peroxide. The oral tissue must be carefully isolated to prevent soft tissue irritation and ingestion. The most common method of isolation is by using paint-on or rubber dams. Protective eyewear must also be used by patients undergoing in-office bleaching, as is the case anytime a curing light is used and aerosols are created. An example of the steps involved in in-office whitening are shown in figures 11-17. Figure 15. Whitening gel removal with air/water syringe after recom- Figure 11. Application of paint-on dam for gingival protection mended period of time

www.ineedce.com 5 Figure 16. Removal of dam Figure 20. Placement of the tray in the upper arch

In-office whitening treatments provide immediate results while take-home products can take days or weeks to provide Figure 17. Final results demonstrating significant whitening the same result. In-office whitening procedures commonly employ the use of chemically activated whitening systems, while other systems are light activated. Tooth whitening due to dehydration can occur in some cases of light activated in-office whitening. In such cases rebound can occur making the teeth look darker than they looked immediately following the whit- ening procedure, potentially leading to patient dissatisfaction. The peroxide concentration of take home bleaching agents are generally lower than in-office whitening agents. This is due to the lack of professional application and supervision with agents applied by the patient. There are advantages and disadvantages to in-office and take-home whitening treatments, just as there are for virtually Figure 18. Before and after chemically activated in-office tooth whitening. any situation with multiple options. The primary advantage of in-office whitening is the same day results. For some patients this may be the best option due to a personal or social event such as a wedding or reunion, receiving an award or starting a new job in the near future. Another consideration for many patients is cost. In-office treatment is commonly more expensive than take-home whitening. Compliance is another consideration. Patients may opt for in-office whitening, or the clinician may Take home whitening involves a simple process as shown recommend in-office treatment if they know from past experi- in figures 19 and 20. The patient should receive instructions ence that compliance is an issue in general. Patients who have to ensure safety which include whitening only for the specified difficulty taking all doses of prescription medication or those period of time once per day and to avoid overfilling the trays. who have had past compliance issues with take-home whiten- ing may be good candidates for in-office treatment. Figure 19. Application of whitening gel to facial surface of tray The advantages of in-office whitening are the same day results and the lack of compliance issues. The cost may be perceived to be a disadvantage by some patients. The primary advantage of take-home preparations is the lower cost. Disad- vantages of take-home treatments include the longer time frame to achieve the end results and the potential for non-compliance.

Tooth Whitening Contraindications Patient selection is critical when tooth whitening is being considered by the patient or recommended by the clinician. Women who are pregnant or nursing should avoid all whiten- ing procedures and products. There is no research demonstrat- ing safety during pregnancy or while nursing. Children should be carefully screened. Tooth whitening for patients below the

6 www.ineedce.com age of 15 should only be provided with careful consideration. heat, acids, pressure and chemicals, among others, to the nerve Patients in this age category should only be treated under endings in the . The basis of this theory is that the fluid dental professional supervision. Patients with gum disease, filled dentinal tubules are open to the oral cavity at the dentinal especially periodontitis, should defer esthetic procedures of all surface as well as within the pulp. types, including tooth bleaching, until the disease is controlled. There is some evidence that peroxide compounds kill Figure 21. Brannstrom’s hydrodynamic theory. and may thereby be beneficial to the gingiva, but tooth whiten- ing should never be considered or cited as a viable primary or Fluid travels through tubule adjunctive treatment option for periodontal disease. Patients and excites nerve with significant restorative needs should have these addressed prior to whitening the teeth. Other contraindications may include exposed root surfaces, xerostomia or a history of hyper- sensitivity. Individuals with dental restorations involving the facial surfaces of teeth in the esthetic zone must be advised that the restorations will not respond to the whitening agents. This includes composite restorations, hybrid restorations, crowns, veneers, bridgework or any other dental restorative material. Patients should be advised that whitening procedures will only have an effect on natural tooth surfaces and that restorations may need to be replaced after whitening the teeth. Stimuli on exposed dentin cause uid Issues Associated with Tooth Whitening movement in tubule Potential side effects of tooth whitening are changes to the properties of dental restorations. There is significant variability Sensitivity is subjective and transient with symptoms usu- of whitening agents including concentration, duration of con- ally disappearing in a matter of hours or a few days. tact and pH, among others. Some studies have shown no effects Some whitening agents will dehydrate the teeth, particularly on dental restorations. Other studies have shown an increase in if they are anhydrous, and this can also contribute to sensitivity. surface roughness and decrease in hardness of porcelain resto- The dehydration can make the teeth appear whiter and as the rations. Other studies have shown deleterious effects to glass tooth rehydrates in a short period of time the whiter color dissi- ionomer cements. Numerous studies have demonstrated a po- pates. This phenomenon can easily be mistaken for a transient, tential for changes to composite restorations. Still other studies short duration whitening result, when in reality it was due to have shown changes to color, surface hardness and roughness, dehydration of the tooth. Rebound of whitening effect can also staining susceptibility, microleakage and elution, in which the occur in which the pre-treatment discoloration of the teeth composite material washes out of the restorations. The large reappears. Hydrogen peroxide changes the color of the stain number of variables and inconsistent study results prevents de- molecules, rather than actually removing them. Over time, the finitive conclusions regarding the effect of whitening agents on stained appearance can reappear. restorations at this time. However, caution should be advised Prior to whitening treatment, a thorough conversation with all tooth whitening systems due to the potential negative with the patient especially those who experience sensitivity to effects on dental restorations and materials from improper use. temperature variation. Discussing the potential for sensitivity Survey research has indicated that the most frequently re- to patients prior to undertaking treatment will help the pa- ported issue with whitening treatment is sensitivity, followed tient make an informed decision. Thorough documentation of by soft tissue irritation. Gingival, lingual, palatal or mucosal pre-op conversations is important as well. The manufacturers irritation is caused by exposure of the tissue to the bleaching of whitening materials have addressed sensitivity by adding agent. Ill-fitting or overfilled take-home trays can result in tis- different compounds to the bleaching agent. These include sue exposure and irritation. Improperly applied paint-on dam amorphous calcium phosphate, and fluoride, can expose the tissue to damage during in-office whitening. among others. Some in-office light activated whitening equip- Tooth sensitivity has been an issue since whitening materi- ment have variable intensity lights to help manage sensitivity. als were first introduced. The most widely accepted theory explaining the mechanism of tooth sensitivity is Brannstrom’s Addressing Patient Expectations hydrodynamic theory, first described in 1966. Brannstrom’s the- It is critically important to discuss each patient’s expectations ory indicates that stimuli are transmitted to the pulp from fluid prior to undertaking whitening treatment. A thorough clinical movement in the dentinal tubules. The inward and outward flow and radiographic examination must precede esthetic treatment. of fluid acts as the medium conveying stimuli including cold, Patients who are pregnant, have xerostomia, exposed root

www.ineedce.com 7 surfaces or those with generalized thermal sensitivity need to and public speakers. Among the reasons cited by individuals be informed that they are not candidates for tooth whitening. who whiten their teeth are self-esteem and confidence in social Patients who are allergic to peroxides must be excluded as well. and business situations. Tooth whitening is the number one Systemic contraindications include patients with asthma or cosmetic procedure because it’s the most affordable way to other respiratory conditions, uncontrolled diabetes or cancer. significantly improve one’s appearance. Patients with restorations in the esthetic zone need to be in- Further developments in whitening procedures and materi- formed that they may need to be redone to match the shade of als will continue in the future. Improvements in the predict- the teeth after whitening. Patient’s expectations should also be ability of the results, outcomes and reductions is side effects discussed if the teeth have bands of discoloration or very dark will benefit our patients and our practices. teeth prior to whitening. Once it has been determined that a patient is a good candidate for whitening and all other dental Bibliography Hasegawa H, et al. Antimicrobial effects of carbamide peroxide against a needs have been addressed, a discussion of the potential side ef- polymicrobial biofilm model. Am J Dent. 2015 Feb;28(1):57-60. fects should occur. Among the topics that must be discussed is Bartold PM. Dentinal hypersensitivity: a review. Australian Dental Journal the possibility for hypersensitivity, soft tissue inflammation or 2006;51:(3):212-218. other side effects. The final shade that will be achieved cannot Arndt A, et al. Clinical effectiveness of flash teeth whitening, a novel method for be guaranteed without risking patient dissatisfaction. The po- teeth bleaching. Compend Contin Educ Dent. 2014 Jun;35(6):e25-28. tential for rebound of the discoloration must also be mentioned, Kwon SR, et al. Effect of various tooth whitening modalities on microhardness, surface roughness and surface morphology of the enamel. Odontology. 2014 Jun 28. as well as the possibility of non-uniform results. Some patient’s [Epub ahead of print]. teeth have a streaky or blotchy appearance after whitening. This Strassler HE. What’s up with whitening? An update on professionally dispensed vital usually self corrects in a short period of time. In some instances, bleaching. ADTS. www.ineedce.com. Accessed November 2006. the non-uniform results are due to dehydration which correct Shephard, D. Tooth Whitening Choosing The Best Method. www. toothwhiteningvault.com/articles/tooth-whitening-choosing-the-bestmethod. in a few hours or days. The need for thorough documentation Accessed November 2006. cannot be overstated. 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Copenhagen: Munksgaard, 1970. Ideally at this point the patient selects in-office or take- p221. home whitening. Prior to undertaking whitening treatment a Strassler HE. Update on toothwhitening systems. J Esthet Dent 1990;2:151–153. pre-op shade must be selected, having the patient participate Strassler HE. Update on toothwhitening systems. J Esthet Dent 1990;2:151–153. in the initial shade selection. For patients who select take-home Leonard RH, Haywood VB, et al. Nightguard vital bleaching of tetracycline-stained whitening, they should be instructed to whiten until the desired teeth: 54 months post treatment. J Esthet Dent 1999;11:265–277. shade is achieved, rather than for a pre-determined number Matis BA, Wang Y, et al. Extended at-home bleaching of tetracycline-stained teeth of days. Appearance in general is subjective and the patient’s with different concentrations of carbamide peroxide. 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Quintessence Int 1998;29:503–507. general, in photographs, in social or business situations due Matis BA, Mousa HN, et al. Clinical evaluation of bleaching agents of different to the appearance of their teeth can experience a life changing concentrations. Quintessence Int 2000;31:303–310. outcome from tooth whitening. There are many reasons why Haywood VB. Treating sensitivity during tooth whitening. Compend Contin Educ Dent. 2005;26(9 Suppl 3):11–20. people whiten their teeth but the underlying motivation is Christensen GJ, Christensen RP. Home use bleaching study — 1995. CRA the desire for a better looking smile. There are many reasons Newsletter 1995;19(10):1. why people want to enhance their appearance including career Ibid. advancement. The obvious examples include models, televi- Nathoo S, Santana E 3rd, Zhang YP, et al. Comparative seven-day clinical evaluation sion and movie actors. Others include corporate executives of two tooth whitening products. 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Colour and surface analysis of carbamide peroxide bleaching effects on the dental restorative materials in situ. J Dent. 2009;37(5):348-56. Epub Brunton PA, Ellwood R, Davies R. A six-month study of two self-applied tooth 2009 Feb 8. whitening products containing carbamide peroxide. Oper Dent. 2004;29(6):623–626. Hubbezoglu i, Akaoglu B, Dogan A, Keskin S, Bolayir G, Özçelik S, et al. Effect Basting RT, Rodrigues AL Jr, Serra MC. The effect of 10% carbamide peroxide, of bleaching on color change and refractive index of resins. Dent carbopol and/or glycerin on enamel and dentin microhardness. Oper Dent. Mater J. 2008;27(1):105-16 2005;30(5):608–616. Wattanapayungkul P, Yap AUJ, Chooi KW, Lee MFLA, Selamat RS, Zhou RD. Cavalli V, Arrais CA, Giannini M, Ambrosano GM. High-concentrated carbamide The effect of home bleaching agents on the surface roughness of tooth-colored peroxide bleaching agents’ effects on enamel surface. J Oral Rehabil. 2004;31(2):155– restoratives with time. Oper Dent. 2004;29(4):398-403. 159. Moraes RR, Marimon JL, Schneider LF, Correr Sobrinho L, Camacho GB, Bueno Spalding M, Taveira LA, de Assis GF. Scanning electron microscopy study of dental M. Carbamide peroxide bleaching agents: effects on surface roughness of enamel, enamel surface exposed to 35% hydrogen peroxide: alone, with saliva, and with 10% composite and porcelain. Clin Oral Investig. 2006;10(1):23-8. Epub 2005 Nov 16. carbamide peroxide. J Esthet Restor Dent. 2003;15(3):154–164. Villalta P, Lu H, Okte Z, Garcia-Godoy F, Powers JM. Effects of staining and bleaching Basting RT, Rodrigues AL Jr, Serra MC. The effects of seven carbamide peroxide on color change of dental composite resins. J Prosthet Dent. 2006;95(2):137-42. bleaching agents on enamel microhardness over time. J Am Dent Assoc. 2003;134(10):1335–1342. Türkün LS, Türkün M. Effect of bleaching and repolishing procedures on coffee and tea stain removal from three anterior composite veneering materials. J Esthet Restor Justino LM, Tames DR, Demarco FF. In situ and in vitro effects of bleaching with Dent. 2004;16(5):290-302. carbamide peroxide on human enamel. Oper Dent. 2004;29(2):219–225. Christensen GJ, et al. Home use bleaching study-1995. CRA Newsletter Leonard RH Jr, Garland GE, Eagle JC, Caplan DJ. Safety issues when using a 16% 1995;19(10):1. carbamide peroxide whitening solution. J Esthet Restor Dent. 2002;14(6):358–367. Nathoo S, et al. Comparative seven-day clinical evaluation of two tooth whitening Strassler HE. What’s up with whitening? An update on professionally dispensed vital products. bleaching. ADTS. www.ineedce.com. Accessed November 2006. Compend Contin Educ Dent. 2001;22(7):599-604,606). Matis BA, Gaiao U, Blackman D, et al. In vivo degradation of bleaching gel used in whitening teeth. J Am Dent Assoc. 1999;130(2):227–235. Kossatz S, et al. Tooth sensitivity and bleaching effectiveness associated with use of a calciumcontaining in-office bleaching gel. J Am Dent Assoc. 2012 Dec;143(12):e81-7. Strassler HE. What’s up with whitening? An update on professionally dispensed vital bleaching. ADTS. www.ineedce.com. Accessed November 2006. Basting R, et al. Clinical Comparative Study ofthe Effectiveness of and Tooth Sensitivity to 10% and 20% Carbamide Peroxide Home-use and 35% and 38% Giniger, M, Bastini, T, Olsen, B. Assessment of enamel surface effect caused by Hydrogen Peroxide In-office Bleaching Materials Containing Desensitizing Agents. aqueous cleaning technology. J Dent Res, abstract 91293, accepted for publication Oper Dent. 2012 Sep-Oct;37(5):464-73. doi: 10.2341/11-337-C. Epub 2012 May 18. Spaid, M, Giniger, M. Effect of adjunctive universal whitening enhancer on enamel He LB, et al. The effects of light on bleaching and tooth sensitivity during in-office and dentin. IADR 2006; Abstract 1665. vital bleaching: a systematic review and meta-analysis. J Dent. 2012 Aug;40(8):644- Sulieman M. An overview of tooth discoloration: extrinsic, intrinsic and internalized 53. doi: 10.1016/j.jdent.2012.04.010. Epub 2012 Apr 21. stains. Dent Update. 2005 Oct;(8):463-4, 466-8, 471. Dawson PF, et al. A clinical study comparing the efficacy and sensitivity of home vs Kurthy R. Dentaltown. Why we see problems with teeth whitening: The science of combined whitening. Oper Dent. 2011 Sep-Oct;36(5):460-6. doi: 10.2341/10-159-C. whitening. Part 1. 2012 Nov:92-99. Epub 2011 Aug 22). Margeas, R. New advances in tooth whitening and dental cleaning technology. www. ineedce.com/ courses/1464/PDF/NewAdvancesinTooth.pdf. Author Profile Reference: www.nlm.nih.gov/medlineplus/ency/ article/003065.htm. Dr. Richard Nagelberg has been practicing general dentist- Goldberg M, et al. Tooth bleaching treatments: A review: Association Dentaire ry in suburban Philadelphia for 32 years. He has international Francaise, Paris, 2005. practice experience, having provided dental services in Thai- Klukowska M. Analysis of surface stains treated with whitening formulations. 81st General Session of the International Association for Dental Research. 2003. land, Cambodia, and Canada. He is co-founder of PerioFrogz. Duchner H, et al. Bleaching effects on subsurface enamel and coronal dentin. com, an information services company, and an advisory board IADR/AADR/CADR. 82nd General Session. 2004;(March 10-13). member, speaker, key opinion leader and clinical consultant Ontiveras, JC, Paravina RD. Color change of www.ineedce.com 11 vital teeth for several dental companies and organizations. Richard has a exposed to bleaching performed with and without supplementary light. J Dent. 2009 Nov;37(11):840-7. doi: 10.1016/j.jdent.2009.06.015. Epub 2009 Jun 30. monthly column in Dental Economics magazine, “GP Perio- Ontiveros JC. In-office vital bleaching with adjunct light. Dent Clin North Am. 2011 The Oral-Systemic Connection”. A respected member of Apr;55(2):241-53, viii. doi: 10.1016/j.cden.2011.01.002. the dental community, Richard lectures internationally on a Leonard RH, et al. Use of different concentrations of carbamide peroxide for variety of topics centered on understanding the impact dental bleaching teeth: an in vitro study. Quintessence Int. 1998;29:503-507. professionals have beyond the oral cavity. Dr. Nagelberg can Matis BA, et al. Clinical evaluation of bleaching agents of different concentrations. Quintessence Int. 2003;31:303-310. be reached at [email protected]. A clinical evaluation comparing two H2O2 concentrations used with a light-assisted chairside tooth whitening system. Ward M, Felix H. Compend Contin Educ Dent. Author Disclosure 2012 Apr;33(4):286- 91. Dr. Nagelberg is Editorial Director, Dental Education, PennWell El-Murr J, et al. Effects of external bleaching on restorative materials: A Review. Publishing.

www.ineedce.com 9 Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. The color of an individual’s teeth results 11. Which of the H2O2 breakdown products 20. Patient documentation should include: from: breaks carbon to carbon double bonds? a. The essential nature of the dialogue between a. Intrinsic and extrinsic color molecules a. H2O clinician and patient b. Intrinsic and interior color molecules b. The unpaired oxygen free radical b. Potential contraindications c. Extrinsic and exterior color molecules c. Both a and b c. Patient expectations d. Superficial stains only d. None of the above d. All of the above 2. Which of the following can increase the 12. Carbamide peroxide breaks down into: 21. Consumption of foods rich in which of the discoloration of teeth? a. Hydrogen peroxide and urea following increases extrinsic staining? a. Alkaline compounds a. Trauma b. Hydrogen peroxide and H2O b. Polyphenols b. Surface irregularities c. Hydrogen peroxide and oxygen d. Free radicals c. Acidic compounds c. Enamel pits and fissures d. All of the above d. All of the above 13. Which of the following is true regarding 22. It is ethical to provide tooth whitening 3. The American Dental Association’s managing tooth patient expectations with tooth whitening procedures? services: position on tooth whitening states: a. When undertaken as part of a properly sequenced a. Tooth whitening is appropriate for everyone with a. Discussions should be undertaken during the treatment treatment plan dark teeth b. Without a radiographic examination b. Tooth whitening can be undertaken after a thorough b. Potential side effects should be addressed when they occur c. Without a clinical examination exam d. All of the above c. The final shade of the teeth can be guaranteed prior c. Tooth whitening can be undertaken as part of a to whitening 23. Which of the following is correct regarding properly sequenced treatment plan d. None of the above tooth whitening for adolescent patients? d. Both b and c 14. Brannstrom’s hydrodynamic theory a. Careful screening is required 4. The most common side effects of tooth b. Patients under 15 should only be treated after careful indicates; consideration whitening are: a. Static fluid in the dentinal tubules increases a. Sensitivity and periodontitis c. Professionally supervision is critical sensitivity d. All of the above b. Sensitivity and b. Movement of particles in the dentinal tubules c. Sensitivity and soft tissue irritation increases sensitivity 24. In-office whitening procedures typically d. Sensitivity and caries c. Movement of fluid in the enamel increases use H2O2 concentrations of: 5. Causes of intrinsic staining include; sensitivity a. 20-30% b. 40-50% a. Frequent consumption of darkly brewed d. None of the above c. 25-35% tea 15. Which of the following conditions may be d. 35-45% b. Trauma contraindications for tooth whitening? c. Medications a. Xerostomia 25. Breaking down the carbon to carbon d. Both b and c b. Previous thermal sensitivity double bonds in stain molecules: a. Removes the stain 6. Tooth sensitivity association whitening is: c. Compliance issues d. All of the above b. Lightens the stain a. Permanent c. Has no effect on the stain b. Always severe 16. Which of the following is true regarding d. Darkens the stain c. Transient advantages and disadvantages of in-office d. None of the above 26. Setting patient expectations prior to tooth and take-home tooth whitening? whitening includes all of the following except: 7. Contraindications to tooth whitening a. The primary advantage of take-home whitening is a. Side effect development include all of the following except: the same day results b. Non-uniform initial results a. Active periodontal disease b. The primary advantage of in-office whitening is the c. Improved periodontal condition b. 18 years of age same day results d. Replacement of restorations c. Pregnancy c. The primary disadvantage of take-home whitening is the cost 27. Soft tissue irritation from tooth whitening 8. Which of the following is true regarding d. The primary disadvantage of in-office whitening is may be caused by: tooth coloration? compliance a. Ill-fitting trays a. Intrinsic stains can become extrinsic stains b. Improperly applied barriers 17. Materials used to reduce sensitivity include c. Peroxide whitening agents b. Extrinsic stains can become intrinsic stains all of the following except; c. Extrinsic stains are the result of organic pigments d. All of the above a. Amorphous calcium phosphate 28. Peroxide whitening agents work by: incorporation during tooth formation b. Potassium nitrate d. None of the above a. Making single bonds into double bonds c. Amorphous calcium nitrate b. Breaking double bonds into single bonds 9. Which of the following is true regarding d. Variable light intensity c. Making double bonds into triple bonds the FDA’s position on tooth whitening 18. Gingival, lingual, palatal or mucosal d. Breaking triple bonds into single bonds procedures? irritation is caused by: 29. Which of the following affects color a. FDA approves whitening procedures a. Exposure of the tissue to the bleaching agent perception? b. FDA regulates whitening procedures b. Ill-fitting or overfilled take-home trays a. Absorption of light c. FDA has not taken a position on whitening c. Improperly applied paint-on dam b. Light reflection procedures d. All of the above c. Dentin d. None of the above 19. Studies have shown changes in composite d. All of the above 10. Which of the following is generated by restorations after tooth whitening 30. Isolation during in-office whitening H2O2? including: include all of the following except: a. Free radicals a. Elution a. Vinyl dam b. H2O b. Improved surface hardness b. Paint-on dam c. Both a and b c. Reduced surface roughness c. Tofflemire band d. None of the above d. Increased longevity of the restoration d. and cheek retractors

10 www.ineedce.com ANSWER SHEET A Review of Tooth Whitening Services

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

If not taking online, mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. 1. Discuss the primary responsibilities of dental professionals. P.O. Box 116, Chesterland, OH 44026 2. Describe the available tooth whitening agents and their mechanism of action. or fax to: (440) 845-3447 3. Discuss the potential benefits and side effects of tooth whitening agents. 4. Describe the different types of tooth staining. For IMMEDIATE results, go to www.ineedce.com to take tests online. Course Evaluation Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. 1. Were the individual course objectives met? Payment of $59.00 is enclosed. Objective #1: Yes No Objective #2: Yes No (Checks and credit cards are accepted.) Objective #3: Yes No Objective #4: Yes No If paying by credit card, please complete the following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will show up as PennWell 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 1. 16. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 2. 17. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 3. 18. 4. 19. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 5. 20. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 6. 21. 10. Do you feel that the references were adequate? Yes No 7. 22. 11. Would you participate in a similar program on a different topic? Yes No 8. 23. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 9. 24. ______10. 25. 13. Was there any subject matter you found confusing? Please describe. 11. 26. ______12. 27. 14. How long did it take you to complete this course? 13. 28. ______14. 29. 15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD Code 781 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/ many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from IMAGE AUTHENTICITY their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2011) to (10/31/2015) Provider ID# 320452 The images provided and included in this course have not been altered. California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. © 2015 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell ULWHT715DIG www.ineedce.com Customer Service 216.398.7822 11

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