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After studying this chapter, the student will be able to do the following:
1. List the indications and contraindications for use of the patient-applied, professionally supervised whitening technique.
2. Recall the indications and contraindications for professionally applied power whitening techniques.
3. Outline the steps in the clinical phase of patient-applied, professionally supervised vital whitening technique.
4. Identify the essential elements of home care instructions for the patient using the professionally supervised, self-applied technique.
5. Summarize the steps in construction of the whitening tray, and identify the equipment and materials used.
6. Outline the steps in the professionally applied power whitening technique. Identify the equipment and materials used.
body dysmorphic disorder (BDD)
custom whitening tray
paint-on resin dam
shade guide tab
Delivery of the patient-applied and professionally applied “power” whitening techniques may be shared between the dentist and the dental hygienist. The critical elements of both techniques include the patient’s medical history, intraoral examination, discussion of benefits and risks, informed consent, collection of data, record maintenance, detailed patient instruction, and follow-up evaluation. The hygienist may assume many of these responsibilities.
Patient-applied whitening or professionally applied power whitening is generally effective on vital teeth that are affected by slight-to-moderate intrinsic staining. Yellow, orange, and light brown intrinsic stains are more receptive to whitening than are dark blue–gray and dark brown stains. White spots can be difficult to mask with whitening. Tetracycline staining becomes more difficult to treat as the degree of staining intensifies. Extrinsic stains are more easily whitened than are intrinsic stains; however, a prophylaxis may be all that is necessary to obtain the desired esthetic result.
Teeth that have been stained as a result of caries, pulpal necrosis, or endodontic therapy are not good candidates for patient-applied whitening. Stains caused by amalgam restorations also resist whitening. Teeth with sensitive root surfaces should not be whitened aggressively because of the potential for increased tooth sensitivity. A small minority of patients may be sensitive or allergic to a component in the whitening agent, and occasionally, a patient may not exhibit the degree of motivation and/or cooperation that is necessary for successful treatment. Table 31.1 lists the indications and contraindications for the use of patient-applied, professionally supervised vital whitening.
TABLE 31.1. Indications/Contradistinctions for Patient-Applied, Professionally Supervised Whitening
Professionally applied power whitening should not be used on patients with photosensitivity due to drugs or herbal supplements. Patients undergoing chemotherapy or radiation therapy must not be bleached with the power technique. Patients with a history of melanoma should avoid the power bleaching systems because of the potential exposure to harmful light sources. Severe intrinsic stains, cervical erosion/sensitivity, cracks in the enamel, caries, and anterior restorations not scheduled for replacement are also contraindications for power whitening procedures. Local anesthesia must not be used as tissues could be harmed when patient sensations are not present. Nonvital teeth may undergo professionally applied power bleaching systems. Table 31.2 lists indications and contraindications for the professionally applied power whitening.
TABLE 31.2. Indications/Contradistinctions for Professionally Applied Power Whitening
Before whitening treatments are prescribed, the patient’s medical history should be thoroughly reviewed. The procedure is contraindicated in the following patients:
- Pregnant or lactating women
- Children under the age of 18 years without parental consent
- Heavy smokers
- Patients who are sensitive to any ingredient in the whitening agent
- Anterior restorations that will not be replaced
III. Clinical Procedure—Three Patient Appointments for Professionally Monitored Patient-Applied Tray Whitening
Professionally prescribed whitening agents for patient application are available in the popular kit form, which contains all the necessary supplies for an average treatment sequence. The following is a brief description of the recommended clinical procedure for vital tooth bleaching using carbamide peroxide agents. Necessary items for this procedure are listed in Table 31.3.
TABLE 31.3. Armamentarium for the Clinical Procedure for Processionally Supervised Whitening
A. First Appointment
A summary of the clinical procedures in this section can be found at the end of the chapter.
1. Medical History
Obtain a complete medical history from the patient. Other than conditions listed above or a sensitivity or allergy to hydrogen peroxide or carbamide peroxide or other ingredients contained in the bleaching agent, there are no medical contraindications.
2. Informed Consent
An informed consent should be read and signed by the patient at this time. The informed consent form should briefly describe the bleaching procedure as well as the possible benefits and side effects. The informed consent should become a part of the patient’s record. A sample consent form is illustrated in Figure 31.1.
FIGURE 31.1. Informed consent form for patient.
3. Intraoral Examination
Perform a complete intraoral examination. Examine the soft tissues for lesions, which would be irritated by the tray or the bleaching agent. Examine the teeth for caries, exposed root surfaces, exposed dentin, and broken or cracked restorations as well as teeth. Any findings from this exam should be documented in the patient’s record.
Perform a prophylaxis. Scale and polish the teeth to remove plaque, calculus, and stain.
5. White Swabs
White stain remover swabs with aqueous cleaning technology are available. The swabs known as Power Swabs, Whitening Enhancement Swabs, and GRINrx Whitening Stain Remover Swabs (Power Swabs Corporation, Beaverton, OR) may also be used to enhance bleaching. The tabs are swabbed gently over all surfaces to be whitened. The swab removes stains, prepares surface for whitening, and reduces sensitivity through its hydration properties.
6. Intraoral Photograph
Take an intraoral photograph showing both the upper and lower teeth. In this photograph, include a shade guide tab that is matched to the shade of the anterior teeth, Figure 31.2A. The tab may be positioned adjacent to the incisal edge of a central incisor. Figure 3.4 shows a VITA shade guide. Intraoral color-measuring devices, such as the spectrophotometer shown in Figure 31.2B, may also be used to document the initial tooth color.
FIGURE 31.2. A. Photograph of anterior teeth and shade guide for color evaluation and pre-/post-op records. B. Photograph of an intraoral spectrophotometer, a clinical color-measuring device. (Courtesy of Shofu Dental Corp.)
7. Full-Arch Impression
Take a full-arch alginate impression of the teeth that are to be whitened. Carefully pour the impression in dental stone. The whitening tray is fabricated on the stone model before the next appointment.
B. Second Appointment
1. Test Fit
Try the custom tray in the patient’s mouth, and make any necessary adjustments. Figure 31.3 shows a custom tray in place over the maxillary teeth. The tray should not impinge on frenal attachments.
FIGURE 31.3. Custom resin whitening tray in place over the maxillary teeth.
2. Patient Instruction
Instruct the patient regarding use of the tray. The patient may wear the tray at night or during the day. When used at night, the tray is worn over the teeth while the patient sleeps. When used during the day, the tray is worn twice daily for 1 hour each. On average, initial results are achieved in 2 weeks; however, longer treatment may be required to achieve the desired result.
a. Load the tray with fresh whitening agent before each treatment. Do not fill the tray completely. Fill only the space that is created by the reservoirs in the tray; use only one dot of material per facial surface.
b. Place the tray firmly over the teeth. Wipe any excess whitening agent from outside the tray with fingers or a piece of gauze.
c. Do not swallow the excess whitening agent.
d. Remove the tray at the end of each treatment period, and rinse it with cold water.
e. Brush the teeth and rinse the mouth at the end of each treatment.
f. Store the tray in the storage box between treatments. Do not expose the tray or box to heat.
g. Record each whitening treatment with the date and the hours treated.
3. Side Effects
Describe the possible side effects, such as tooth sensitivity or soft-tissue irritation (gums, lips, or cheeks), to the patient. Instruct the patient to call the office should any side effects occur. If the teeth become sensitive, the patient should discontinue treatment until the sensitivity disappears and then begin treatment again with a reduction in the daily treatment time. Tooth sensitivity can be effectively treated with application of neutral sodium fluoride or potassium nitrate in the whitening tray twice daily for 1 hour each.
4. Written Instructions
Give the patient written instructions. These instructions should include space to record the date and length of treatment (Fig. 31.4).
FIGURE 31.4. Patient-instruction form.
5. Follow-up Appointment
Schedule an appointment for the patient to return when the treatment is completed. The duration of treatment may vary but usually requires 2 to 6 weeks. Whitening one arch at a time will allow the patient to better visualize the results of treatment by allowing comparison between treated and untreated teeth.
C. Third Appointment
Examine the patient for results of the whitening treatment. Record the total amount of treatment in hours, and note any negative side effects.
2. Additional Whitening
If additional whitening is desired, dispense more whitening agent to the patient, and schedule an appointment for a follow-up examination at the end of a sufficient treatment sequence (usually 2–4 weeks).
3. Intraoral Photograph
When the desired result has been achieved, take a posttreatment intraoral photograph of the treated teeth, including a matching shade guide tab (as in the first photograph, Fig. 31.2A). Together with the pretreatment photograph, this photograph becomes part of the patient’s record to document the results of the bleaching treatment. Alternatively, a new color measurement with an intraoral color-measuring device can be used to document the color change.
The Skill Performance Evaluation sheet for patient protocol and bleaching tray fabrication as a clinical procedure is located in Appendix 2.
IV. Laboratory Procedure—Constructing the Custom Tray
The custom whitening tray is made of clear vinyl resin. A stone model is produced from an alginate impression, and the custom tray is fabricated on the model. Many of the oral appliances discussed in Oral Appliances are constructed in a similar way. Necessary items for the laboratory procedure are listed in Table 31.4.
TABLE 31.4. Armamentarium for Tray Construction