Susan McMahon, DMD AAACD Modern Adhesive Dentistry: Real World Esthetics For presentation and more info from Catapult Education Text SusanM to 33444 Susan McMahon DMD • Accredited by the American Academy of Cosmetic Dentistry: One of only 350 dentists worldwide to achieve this credential • Seven times named among America’s Top Cosmetic Dentists, Consumers Research Council of America • Seven time medal winner Annual Smile Gallery American Academy of Cosmetic Dentistry • Fellow International Academy Dental-Facial Esthetics • International Lecturer and Author Cosmetic Dental Procedures and Whitening Procedures • Catapult Education Elite, Key Opinion Leaders Pittsburgh, Pennsylvania Cosmetic dentistry is comprehensive oral health care that combines art and science to optimally improve dental health, esthetics, and function.” Why Cosmetic Dentistry? Fun Success dependent upon many disciplines Patients desire Variety cases/materials services Insurance free Professionally rewarding Financially rewarding Life changing for Artistic! patients “Adolescents tend to be strongly concerned about their faces and bodies because they wish to present a good physical appearance. Moreover, self-esteem is considered to play an important role in psychological adjustment and educational success” Di Biase AT, Sandler PJ. Malocclusion, Orthodontics and Bullying, Dent Update 2001;28:464-6 “It has been suggested that appearance dissatisfaction can lead to feelings of depression, loneliness and low self-esteem among other psychological outcomes.” Nazrat MM, Dawnavan D, Yanosvsky JA. Body dissatisfaction, self-esteem, and overweight among inner- city Hispanic children and adolescents. J Adolesc Health 2005;36:267.e16-267.e20 “It has long been recognized that many people seek and undergo orthodontic treatment not to address dental irregularities that might lead to physiologic dysfunction or to prevent destruction of tissues in the oral cavity, but to improve esthetic impairment.” Feu D, Oliveira B, Celeste R,Miguel J AM J Orthod Dentalfacial Orthop, June 2012 Influence of orthodontic treatment on adolescents’ self- perceptions of esthetics Patient Intake Form Would you like whiter teeth? and Are you happy with the way your smile looks? Restorative or Esthetic dentistry should be practiced as conservatively as possible… Adhesive technologies makes it possible to preserve as much tooth structure as feasible while satisfying the patient’s restorative needs and esthetic desires. Professional Tooth Whitening Early Developments • 1960’s Superoxol & Walking Bleach of non- vital teeth, 35% hydrogen peroxide • March 1989: Quintessence International: “Nightguard Vital Bleaching”, Drs. Harald Heymann and Van Haywood • 1994 Britesmile Laser Tooth Whitening Britesmile Laser Tooth Whitening Argon Laser Treatment 50% hydrogen peroxide CO2 Laser Treatment 50% hydrogen peroxide Before/After Tw o h o u r s e s s i o n Argon/CO2 laser w/50% H2O2 in proprietary Delivery system by Britesmile Whitening Today “Number one cosmetic procedure requested by patients 20 -50 years old” “Top cosmetic procedure requested for patients under the age of 20” “Bleaching has increased more that 300% over the past five years American are spending over 1.4 Billlion annually on OTC tooth whitening products $600 Million in revenue for whitening in dental offices More than 1 miillion Americans whiten theiir teeth annually Safety and Efficacy • Schulte JR, Morressette DB, Gasior EJ, Czajewski MV. The effects of bleaching application time on the dental pulp. J Am Dent Assoc 1994:125(10): 1330-1335. • Haywood VB, Leonard RH, Nelson CF, Brunson WD. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 1994; 125(9):1219-1226 • Haywood VB. A comparison of at-home and in-office bleaching. Dent Today 2000;19(4):44-53 • Li Y, Cartwright S, Lezama M, Zhang W, Feller R, Effect of light application on an in-office bleaching gel. JDR 80 January 2001 • Baik JW, Rueggeberg FA, Liewehr FR. Effect of light-enhanced bleaching on in vitro surface and intrapulpal temperature rise. J Esthet Restor Dent (Canada), 2001 13(6):370-378 • Li Y, Effect of Rembrandt Sapphire PAC light on bleaching efficacy on Rembrandt Virtuoso Lightning chairside bleaching gel. Loma Linda University School of Dentistry, January 2002 • Papathanasiou A, Kastalie S, Perry RD, et al. Clinical evaluation of a 35% hydrogen peroxide in –office whitening system. Compend Contin Educ Dent, April 2002, 23(4):335-338 • Shethri SA, Matis BA, Cochran MA, Zekonis R, Stropes M, A clinical evaluation of two in-office bleaching products. Oper Dent 2003;28(5):488-95 • Luk K, Tam L, Hubert M. Effect of light energy on peroxide tooth bleaching. J Am Dent Assoc, Feb 2004, 135(2):194-201 • Yu H, Li Q, Wang Y, Cheng H. Efffects of temperature and in-office bleaching agents on surface and subsurface properties of aesthetic restorative materials. J Dent. 2013;41:1290-1296 • Bonafe E, Bacovis CL, Iensen S, Loguerica AD, Reis A, Kossatz S. Tooth sensitivity and efficacy of in-office bleaching in restored teeth. J Dent. 2013: 41:363-369 • Li Y, Greenwall L. Safety issues of tooth whitening using peroxide-based materials. Brit Dent J. 2013;215L29-4 Hydrogen Peroxide and Carbamide Peroxide based tooth whitening is safe and effective……. …..when manufacturer’s instructions are followed Risks • Increased tooth sensitivity • Gingival irritation • Tooth surface roughening and softening • Increased potential for demineralization • Degradation of dental restorations and/or unacceptable color change of dental restorations Tooth Discoloration • Extrinsic: External staining Smoking Pigments in food or beverages Metals/minerals Detergents and abrasives are used to remove extrinsic stains ie: Smokers toothpastes, prophy pastes Tooth Discoloration • Intrinsic: internal staining genetics age antibiotics fluorosis developmental disorders Peroxide based bleaching used to remove intrinsic staining. The Chemistry • Carbamide Peroxide 10% Carbamide peroxide breaks down in contact with water to roughly 3-4% hydrogen peroxide • Hydrogen Peroxide H2O2 Basic mechanism of tooth whitening still not explained ….dominant THEORY is that stain molecules are oxidized into colorless compounds Dental hard tissues are highly permeable to fluids and greatest fluid flow is interprismatic spaces in enamel and tubules in dentin Tooth whitening is a dynamic process intitiated by the movement of whitening material into the tooth structure…interacting with stain molecules and involving micormorphologic alterations to tooth surface Hydrogen Peroxide Colorless liquid with low molecular weight which allows it to penetrate dentin. In dentin it releases oxygen and breaks the double bonds of organic and some inorganic compounds that cause staining of teeth Penetration of enamel and then dentin is enhanced by : Higher concentration Prolonged application Increased temperature Acid-etching, existing restorations Large Tubules (young teeth) Light Activation Specific formulations and delivery systems Chromogens: 1. Large organic compounds with conjugated double bonds….hydrogen peroxide oxidizes the double bond and makes the chromogen lighter 2. Metallic Compounds….do not react as well to hydrogen peroxide Color Shift is mostly dependent on ….The concentration of peroxide ….The length of time of exposure Whitening Options • Whitening Toothpastes ~ most contain peroxide • OTC Strips ~ peroxide delivered in a strip worn approx 30 min/day • Rinses and Gels ~ Applied with brush or rinsed twice daily • Tray Based Whiteners ~ custom fitted trays with peroxide gels used daily or overnight • In-Office Professional Whitening ~ Higher concentrations of peroxide professionally applied In-Office Whitening • Higher concentrations of peroxides 20% to 40% Hydrogen Peroxide • Protection of soft tissues necessary • Light activation in some systems • 30 – 60 minute treatment time • Shade shift of 1-5 shades can be attained Light Activation Necessary? Effective? Harmful? Increased sensitivity? KPT Laser? Marketing for Whitening Social Media: “Do you know someone who is dreaming of White Christmas?” “Not only the bride wears white” Current Patients: “Do you want whiter teeth?” “Are you happy with the way your smile looks?” In-Office Whitening Consultation Consents Desensitizers Tw o Vi s i t Pr o c e d u r e Touch up Whitening Protocol at our office • Consult/Consents ( Photos and Whitening) Dispense desensitizer. Use 3 days prior to whitening appointment • 1 hour Whitening appt. Isolate/Whiten Dispense home tray x 3- 5 days • One week later: 1 hour Whitening appt. Isolate/Whiten Post op photos, Dispense home tray x 3 days, Dispense Remineralization Paste • Touch Up as needed Consult Appointment Patient Photos – 4 Smile Evaluation Discuss Procedure, risks and benefits Sign consents Dispense desensitizer Desensitizer Potassium Nitrate with Flouride: Sticky gel. Delivered disposable trays. Pt uses for several days prior to whitening. Applying lip protectant Positioning Dry Angles Placing surgical cotton rolls Placing cheek retractor with Tongue retractor Applying Liquid Dam Curing Liquid Dam Total Isolation Retractors, Cotton rolls, Gauze, Liquid Dam, Face Napkin Risks • Increased tooth sensitivity • Gingival irritation • Tooth surface roughening and softening • Increased potential for demineralization • Degradation of dental restorations and/or unacceptable color change of dental restorations Risk: Tissue Burns Avoid with proper isolation with in-office procedures Peroxide Burn After 20 minutes