Planning is essential for whitening treatment because tooth whitening is normally the beginning of the esthetic journey. The dentist needs to prepare a thorough treatment plan for the patient who wants to undertake tooth whitening. It is essential to take time to plan the treatment carefully and to fully explain the options for whitening and any necessary treatment that needs to be undertaken before whitening. When the mouth is assessed for whitening, the basic goals of health improvement and health sustainability should be addressed first. Several considerations need to be taken into account. Because 80% of patients who have had tooth whitening choose to undergo further esthetic or restorative dentistry after whitening, it is essential to plan comprehensively for the patient.
Before assessing the patient, it is important that the dentist understands what the patient needs and wants in terms of dental and oral health. Ask the new patient, “What are your hopes and aspirations for your mouth?” Patients may have specific concerns about the appearance of their teeth that they wish to discuss. Although some patients may not have considered this before, many patients have a dental “wish list” of improvements that they would like to make. When they visit the dentist, they may request specific esthetic improvements.
For most patients, this question has not been asked. It is important to wait a few moments after asking so that the patient has time to think and respond. Allow ample time during the appointment interview for the patient to express thoughts and concerns. When discussing tooth whitening, ask the patient about the shade of white that he or she wishes to achieve. Although there are many shades of white to select, most patients request a natural enhancement of their existing shade. If the patient requests extreme whiteness, the request may be unrealistic. It is essential at this stage to understand whether the patient’s requests are realistic or unrealistic.
This chapter outlines what is required for a thorough examination for whitening and describes how to undertake a whitening treatment plan and how to plan further esthetic treatment to follow whitening. This chapter also demonstrates methods of gathering useful information about patients, emphasizing the importance of medical and dental histories. Patient communication, methods for undertaking a smile analysis, management of patients’ expectations, informed consent, and fee planning for whitening treatment are discussed. Examples of questionnaires and forms are provided, which can be used in the information-gathering process.
Although tooth whitening is an elective esthetic treatment, it also has essential therapeutic benefits; these are discussed in Chapter 24. Before undertaking any esthetic treatment, it is essential that excellent and clear communication be established with the patient. It is essential for the dentist to understand exactly what the patient is requesting, in order to understand the patient’s concerns about his or her tooth discoloration and esthetic needs. Beauty is an abstract and subjective concept, but an essential and ineradicable part of human nature (Etcoff 1999). Culture, age, gender, and time can influence perception of beauty. Because of this subjectivity, it is extremely important to establish good communication between the dentist and patient early, so that both can work toward the same goals. Excellent communication leads to treatment acceptance (Jameson 1994). To provide informed consent, the patient needs to understand the benefits and risks and advantages and disadvantages of treatment; the issues associated with not going ahead with treatment; and the importance of each treatment option that is available. Risks and benefits of the treatment need to be discussed before it commences. This is particularly important when the patient’s expectations exceed the reality of what is possible to achieve. Studies have shown significant differences between dentists’ and patients’ preferences for esthetic dentistry (Brisman 1980).
A questionnaire can be used to evaluate the patient’s hopes and aspirations for his or her smile (see Figure 4.1). The questionnaire can include questions regarding the patient’s self-perception of teeth and smile. Questions should be open-ended, allowing the patient to talk and express any concerns. Patients can be asked about shape, positioning, color, and proportion of teeth. The information gathered will establish a base from which the clinician can interact, communicate, and evaluate the patient’s problems.
The individuality of each case makes esthetic decisions more difficult, but also more interesting and challenging. Patients should be educated and questioned regarding their expectations and perceived final outcome. Before tooth whitening can be undertaken, it is essential to start with a comprehensive dental and oral health evaluation. It is useful to gather information with a checklist so that all the information that is necessary is received.
NEW PATIENT CHECKLIST (SEE TABLE 4.1)
As with any new patient consultation, it is important to obtain or perform the following:
• Consent to undertake an examination.
• Medical history.
• Previous dental history: patient’s attitude toward dentistry, patient’s previous experiences, patient’s expectations.
• Extraoral examination: in addition to assessing for pathology and temporomandibular joint dysfunction, it is essential to do a smile analysis.
• Intraoral examination.
• Soft tissue examination: tongue, palate, and cheek mucosa
• Dental examination
• Periodontal examination
• Occlusal examination
• Assessment of temporomandibular joint function
• Special tests: vitality tests
• Other information:
• Study models
• Face-bow records
• Articulated study models with a diagnostic wax-up if necessary
• Intraoral camera shots
• Digital radiographs
The patient’s medical history should be carefully assessed. Previous history of chronic illness and long-term use of antibiotics—such as minocycline for acne treatment or other antibiotics for chronic infections or perinatal infection—may lead to discoloration of teeth (Antonini and Luder 2011). Individuals who were born prematurely may develop molar incisor hypoplasia (MIH) or multiple white spots on the teeth. A specific whitening questionnaire should be filled out with the patient (see Figure 4.2). Patients’ smoking habits need to be assessed. Patients should not smoke and whiten their teeth. It is essential for those patients who smoke to stop or at least to reduce the amount they are smoking before whitening is undertaken. This can sometimes be used as an incentive for patients to stop smoking altogether.
New patient interview
• Hopes and aspirations
• Listening skills
• Dental history
• Dental issues and checklist
• Radiologic investigation
• Intraoral camera shots
• Clinical photography
• Study casts
• Schedule next appointment for a treatment planning discussion
Allergies to plastic, peroxide, or any of the other ingredients of the whitening system should be noted. Patients’ current medications need to be recorded on the medical history sheet, especially those preparations that cause a dry mouth such as antihistamines. Patients taking hormones sometimes have an exaggerated gingival response. Patients who are pregnant or breastfeeding should be excluded from whitening procedures because there is lack of information concerning possible effects on the developing fetus (Haywood 1995a).
The medical history needs to be stable, and patients with chronic diseases such as ulcerative colitis need to have clearance from their medical doctor before undertaking treatment. Patients undergoing chemotherapy should be in a stable condition before commencing whitening treatment and may need to get clearance from their medical doctor. Patients need to be checked for lichen planus before whitening because in some patients the lichen planus may flare up during the whitening process.
The etiology of the discoloration needs to be assessed because different causes (e.g., caries, internal resorption, external cervical resorption, trauma, medication) necessitate different treatments. It is important to assess dental trauma that the patient has experienced that may affect the long-term prognosis of a tooth and the outcome of the whitening treatment. Severe trauma can lead to both internal and external cervical resorption (Patel et al. 2009). There is insufficient research at present linking home whitening treatments with promotion or exacerbation of resorption.
Extrinsic staining can usually be easily removed with a good dental cleaning and prophylaxis. Establish whether new patients are regular dental attenders or those who visit the dentist only when they have pain; the latter type of patient may not comply with home whitening instructions and may not follow the whitening program or return for review appointments when requested.
SMILE ANALYSIS AND ESTHETICS
What makes a beautiful smile? One definition is one in which the size, position, and color of the teeth are in harmony and the teeth are in proportion and in relative symmetry with one another and with the elements that frame them. Analysis, by definition, means reduction of the component parts to discover the interrelationships (Ricketts 1968). The components of a smile consist of the facial components (the facial features, tooth visibility, age, upper lip curvature, negative space, smile symmetry, and occlusal line) as well as the dental components (the dental midline, axial alignment, tooth arrangement, gradation, shape of the teeth, contact points, and gingival morphology and contour) and the physical components (Rufenacht 1990). The teeth are only part of a greater picture that must be viewed within the frame of the gingival soft tissue, the interarch dark space, the lips (Moskowitz and Nayyar 1995), and the face (Paletz et al. 1994).
Whitening teeth alone may not solve patients’ esthetic requirements (see Figures 4.10 and 4.17). A smile analysis should be conducted before whitening and should be included in the treatment planning stages (Table 4.2). Smile analysis sheets can be used to determine the smile requirements and the patient’s needs (see Figures 4.4 and 4.5). There are many factors to consider when conducting a smile analysis: the shape and length of the teeth, the lip line, the smile line, and the occlusal relationship of the teeth. Each element is an important feature, but all these features are interwoven to create esthetic harmony (Moskowitz and Nayyar 1995).
Stage 1—Emergency treatment: elimination of pain
• Dressings for broken fillings
• Emergency relief of pain; emergency root canal therapy
• Root treatment of any undiagnosed periapical areas before any whitening treatment is undertaken
• Control of infections
• Discussion of possible treatment options, treatment implications, financial arrangements
Stage 2—Elimination of active disease and achievement of oral stability: disease control
• Assessment with indices
• Oral hygiene instruction
• Scaling and prophylaxis
• Root surface debridement (root planning and curettage)
• Other treatment
• Use of fluorides: topical applications, mouthwash
• Dietary counselling
Provisional restorations and simple restorations
• Intracoronal restorations: glass ionomers, composites, amalgams
• Extracoronal restorations: provisional veneers, crowns, bridges, prostheses
• Root canal treatment
• Extractions: routine, surgical
• Occlusal analysis and adjustment
• Referral for advice or treatment
• Other treatment: whitening considered after elimination of active disease
Tooth wear management
• Deep cervical lesions: may require glass ionomer restorations for a well-fitting tray to be made
Stage 3—Definitive restorations: once oral stability has been achieved
• Monitor periodontium
• Monitor caries (inactive lesions)
• Record indices as applicable
• Assess long-term implications with patient (costs, ability to maintain)
• Periodontal: monitoring, crown lengthening, other
• Definitive restorations:
• Veneers and laminates
• Implant fixture placement
• Oral surgery
• Other (including post-treatment photographs)
Stage 4—Maintenance and monitoring at monthly intervals
• Record indices
• Check radiographs
• Review preventive advice: dietary assessment, oral hygiene instruction, fluoride applications
• Oral prophylaxis
• Repeat aspects of stages 2 and if applicable (such as implant abutment connection and implant prosthesis)
Treatment planning time
• Plan time for treatment planning—assess radiographs and photographs and patient’s concerns.
• Prepare written treatment plan; financial responsibilities discussed with the patient at the face-to-face treatment planning discussion.
• Obtain signed financial responsibility form and payment plan.
• Consent form to be signed by patient after explanations of risks, benefits, advantages, and disadvantages.
• Estimated laboratory bill, laboratory work to be returned on time
• Total time estimated
• Appointments scheduled accordingly
• Total fees earned
Adapted from Eaton and Nathan 1998, with permission.
THE COMPONENTS OF A SMILE
The appearance of a smile involves the relationships among the three primary components (Garber and Salama 1996).
• The shade and shape.
• Position, length, and axial alignment.
• The tooth surface characteristics and morphology.
• The shade and shape of the opposing dentition.
• The occlusion and occlusal line.
• The dental midline—an imaginary line that separates the two central incisors.
• The surface texture (e.g., perikymata, stippling, rippling). The surface texture will not change with whitening.
The lip framework
• The lip line—the amount of tooth exposed during a smile.
• The smile line—a hypothetical curved line drawn along the edges of the four anterior maxillary teeth that should run parallel with the curvature of the inner border of the lower lip (Rufenacht 1990).
• The upper lip curvature—the position of the upper lip height relative to the teeth.
• Negative space—the dark space that appears between the jaws between laughter and talking.
• The smile symmetry—the symmetric placement of the corners of the mouth in the vertical plane (see Figure 4.7B).
The gingival scaffold
• The gingival height of contour.
• Appearance of the gingival tissues.
• Symmetry of the heights of the central incisors (see Figure 4.7).
• Incisal and gingival embrasures.
THE GOLDEN PROPORTION
Artists, mathematicians, and philosophers have long been preoccupied with the relationship between beauty and harmony. Harmony in proportion has been regarded as the essential esthetic principle. A simple but profound mathematical ratio (the discovery of which has been attributed to Pythagoras) appears frequently in nature—1:1.618 (Levin 1978). Levin has designed a golden mean gauge in the same proportion (see Figure 4.7). He discovered that the relationship between the widths of the central and lateral incisors were in the golden proportion and that the lateral negative space was in the golden proportion of one-half the width of the anterior segment. This golden mean gauge can help assess the harmony of the face and can help to determine the relationships of the teeth to the lips and to the face and of the teeth to one another. This gauge can help with planning treatment and lengths and shape of teeth for veneers after whitening.
WHAT IS AN IDEAL SMILE?
Photographs of fashion models in the media demonstrate many “ideal” smiles. The smile should be harmonious (see Figure 4.7).
The ideal smile is considered to have the following characteristics:
• Bright (Philips 1996)
• Youthful, regardless of age (Moskowitz and Nayyar 1995)
• Symmetric teeth
• Showing natural teeth
• White to light tooth shade (Dunn et al. 1996)
• Healthy gingival color, harmony, and form (Garber and Salama 1996)
• Gingival line following upper lip contour
• Incisal edge following lower lip contour
Tooth shade was the most important factor in a study conducted by Dunn et al. (1996) to assess patients’ perceptions of dental attractiveness. This was followed in sequence by natural (unrestored) tooth appearance and the number of teeth showing. Whitening is thus an attractive, simple option to lighten the appearance of natural teeth.
The existing condition of the teeth and periodontium needs to be examined before whitening. Defective restorations are noted; these need to be discussed with patients before whitening. The teeth are assessed for the following:
• Thickness of the enamel.
• Existing gingival or cervical recession.
• Existing sensitivity before whitening, which needs to be noted on the patient’s dental chart.
• The translucency of the teeth. Translucent teeth still retain their “blackish” look after whitening (Haywood 1995a). Patients need to be told of this effect to avoid disappointment. Most patients are so happy with their new whiter smile that the existing translucency is of no concern.
• White spots or opacities. These do not disappear during whitening and in the early stages of whitening may become more visible. Patients need to be warned about this.
• Teeth that are banded because of tetracycline staining or desiccation will retain their banded appearance after whitening. These aspects need to be discussed with patients before whitening so the patient is not disappointed with the result.
• Gingivitis. Although whitening teeth improves gingival health, whitening treatment should not be attempted on teeth with surrounding gingivitis or more severe gingival problems (Small 1998).
• Dehydration line. As patients age, if they have a high lip line with a short lip, the lower half of the incisal tip may appear darker. This is because as the patient ages the enamel becomes thinner and the dentin becomes thicker with the laying down of tertiary dentin, allowing the tooth to become age-yellowed. Many patients are concerned about the dehydration line. Patients should be warned that when the teeth whiten, they do not whiten in an even band and can become lighter with a two-toned effect.
• Dark crack lines should be assessed prior to whitening and the patient should be told that the dark crack lines (often due to smoking and/or grinding teeth) will not disappear with whitening treatment.
• Vitality testing of all teeth to be whitened should be undertaken. This can be done using heat or cold temperature testing or electric pulp testers. All test results need to be recorded in the patient’s record.
• Radiographs. Recent radiographs need to be used to check for pathology or existing decay of all teeth. A single screening anterior periapical radiograph can be taken with the aid of a beam-aiming device (see Figure 4.12). However, it is better to have full-mouth periapical radiographs of all teeth to be whitened to ensure there is no previous or existing pathology. Problems have arisen when dentists have not taken an anterior periapical radiograph before whitening. Teeth with existing periapical pathology can develop exacerbations that may be difficult to treat endodontically. Single dark teeth may be nonvital, and these need to be checked before commencement of whitening treatment. The rule is that a periapical radiograph of all discolored teeth should be taken.
• Digital intraoral photographs of each individual tooth, outlining decay, cracks, defects, and problems, are very useful to assess the condition of the tooth and the restoration before whitening.
• Diagnostic wax-up. Sometimes it may be necessary to take study models and have the dental technician make a diagnostic wax-up of how the teeth will appear after the total treatment, because whitening treatment may be followed by porcelain laminate veneers, direct composite bonding, or opening of the vertical dimension with composite bonding or inlays or onlays. The diagnostic wax-up will help the patient to visualize the final result before treatment commences (see Figure 4.10).
PATIENTS WITH EXISTING RESTORATIONS IN ESTHETIC AREAS
It is essential to warn patients with existing matching anterior composite restorations that because the shade of the teeth will change, new composite restorations using a lighter shade composite may be required after whitening. The actual composite restorations do not change color. Sometimes composite restorations that have a black edge around them appear whiter because the black edge disappears. Teeth with caries or defective, discolored anterior restorations can be repaired after whitening. The cariostatic action of the whitening material will stop any progression of the lesion during whitening. Patients should be aware that the restorations can be replaced 2 weeks after the termination of the treatment, because bond strengths to enamel are weakened during whitening.
It is fundamental before commencement of any whitening procedure that the patient’s expectations are assessed. A patient who expects pure white teeth is seldom satisfied (Haywood 1995a). Normally a color change of two shades occurs; this can be demonstrated on a porcelain shade guide before whitening. Patients need to be made aware that some teeth may not whiten and some teeth do not whiten evenly. Darker teeth take longer to whiten. Older patients’ teeth respond well to whitening, although the root surfaces do not whiten as well. It takes longer for older patients’ teeth to whiten. The timing and sequencing of appointments for older patients will be different than for younger patients or those with a lighter shade to start. Patients should be warned of these factors before commencement of whitening, and of the fact that additional bonding procedures may be necessary to place composites at the neck of the roots (Table 4.3).
DENTAL PHOTOGRAPHY FOR TOOTH WHITENING
It is essential to take photographs in a standard way for treatment planning for whitening. It is essential that the photographs are of excellent quality and standardized and that clear before and after shots are achieved. Digital photographs are easy to standardize and crop, and very quickly a library of before and after pictures can be collected. Photographs should also be taken during the whitening treatment. Patients often forget how dark or discolored the teeth were before commencing treatment and may be dissatisfied if they do not notice further shade changes. It helps to photograph the teeth with the baseline porcelain shade tab so that the patients can appreciate the degree of color change when they see the color change on the guide. That is why it is usually best to whiten only one arch at a time—so that a direct color comparison can be made. Normally the upper arch is whitened first because patients notice this more. Lower teeth take longer to whiten, and often the lower canine may have a snow-capped appearance as the whitening starts from the tip of the tooth.
• The existing color of the teeth
• How often the trays are replenished and the solutions are changed
• The time for which the whitening materials are in contact with the teeth
• The concentration of the whitening material
• The rate of oxygen release (different in carbamide peroxide [night] gels versus hydrogen peroxide [day only] gels)
• The nature of the discoloration (e.g., tetracycline staining)