Tooth whitening changed dramatically in the late 1980s when the first commercial tooth whitening agent became available and the nightguard vital bleaching technique was first described in the literature. Fueled by direct consumer marketing and the media’s role in reporting scientific advances, the focus of tooth whitening shifted from the bleaching of individually discolored nonvital teeth or tetracycline-stained teeth to a general desire for a whiter smile for an esthetically conscious public. The demand for tooth whitening has grown almost exponentially in the last 20 years, and tooth-whitening products are now a popular oral care product category. Today, whiter teeth might even be culturally important, because research has shown that a person’s dental appearance can influence how he or she is perceived by others.

Whitening procedures could be indicated for orthodontic patients for a number of reasons. Most children think that their teeth are too yellow, and children are more critical of their tooth color than their own parents and dentists. Younger patients also express a greater preference for white teeth than do older patients, although adults still identify tooth color and poor tooth alignment as the primary factors that influence their satisfaction with their dental esthetics. In view of these findings, it has been suggested that issues of both color aberrations and tooth positioning should be discussed before orthodontic treatment.

Tooth whitening also has been recommended to reduce the appearance of a common complication of orthodontic treatment—white spot lesions. After allowing time for the lesions to remineralize naturally, bleaching is recommended to reduce the contrast between the white spot lesion and adjacent enamel, a conservative approach before microabrasion or restorative treatments are considered. This camouflage technique has been shown to be effective by colorimetry and patients’ evaluations of the outcome. Furthermore, authors of a randomized clinical trial found that patients reported greater satisfaction with their orthodontic outcome when it was followed by cosmetic whitening, irrespective of whether an in-office or an at-home technique was used.

Perhaps the most overlooked application of whitening agents in orthodontics is their ability to maintain or improve oral health during active treatment. As early as 1978, gingival benefits were demonstrated in orthodontic patients by the incorporation of carbamide peroxide into their daily oral hygiene regimen. Research also has shown that the urea component of carbamide peroxide causes a rise in the salivary and plaque pH levels of the mouth, overcoming the intrinsically acidic nature of some bleaching agents. This buffering capacity of urea elevates plaque and salivary pH levels far above the critical pH at which enamel and dentin begin to dissolve, resulting in a potentially cariostatic benefit of carbamide peroxide whitening agents. The use of carbamide peroxide-based whitening products and procedures during active orthodontic treatment could both improve gingival health and reduce caries susceptibility, although the clinical research to confirm this theory is still lacking.

Currently, no data have reported how whitening products and procedures are used by orthodontists in the United States. The purpose of this study was to conduct a nationwide survey of private-practice members of the American Association of Orthodontists (AAO) to assess their current practices regarding tooth whitening.