There has been controversy related to tooth whitening for patients younger than 18 years since the banning of treatment after a directive issued by the Tooth Whitening Working Group for Europe and the Scientific Committee for Europe in 2012 (European Commission Directive on Cosmetics Products 2012), which said that no whitening can be undertaken for patients younger than 18.
Previously, legislation in the United Kingdom had stated that tooth whitening products were classified as cosmetic products. As a result of the directive, no product that contained more than 0.1% hydrogen peroxide was permitted to be used for tooth whitening. That effectively meant that all dentists in the United Kingdom were practicing dentistry illegally if they were supplying their patients with tooth whitening gel that contained more than 0.1% hydrogen peroxide—and there was no effective product that contained the legal limit of 0.1% hydrogen peroxide. However, before the change in the law, there had been no exclusion of an age group.
There have been further clarifications of the legislation after guidelines were issued by the General Dental Council (GDC) and other professional groups such as the British Society of Paediatric Dentistry (British Dental Bleaching Society (BDBS) 2012, Faculty of Dental Surgery 2014, General Dental Council 2014, General Dental Council 2015).
The European Tooth Whitening Group and the Council of European Dentists Working Group on Tooth Whitening are now considering the research on whitening in patients younger than 18, which has shown that it is safe for patients younger than 18 to whiten their teeth, although it may be some years before the Group reports its findings.
For some children who have tooth discoloration or dyschromia, it is of great concern. Some children have inherently yellow teeth when the secondary teeth erupt as “butter teeth” (Haywood 2006). This deep yellow color affects the child’s self-esteem; he or she may be teased or bullied at school and called derogatory names, which can cause psychological harm. Treatment may be sought to whiten the teeth and remove the distressing discoloration. For these and other children, whitening is an essential treatment option. The purpose of this chapter is to examine the need for treatment of patients younger than 18 and to assess who should be exempt from this legislation. An index of whitening need will be introduced to help clarify which children should undergo whitening based on treatment need.
AN INDEX FOR TREATMENT NEED
Over the last few decades, various indices have been devised for treatment need, such as the Index of Orthodontic Treatment Need [IOTN] in orthodontics (Brook and Shaw 1989), Falcon’s restorative dentistry index (Falcon et al. 2001), the Dental Aesthetic Index (DAI) (Cons et al. 1986), and the Index of Complexity, Outcome and Need (ICON) (Daniel and Richmond, 2000), which is highly weighted towards esthetics; hence, it is more subjective than objective. The IOTN lists grades in increasing severity, and these are used as guidelines to determine when orthodontic treatment is necessary (Puri et al. 2015). It has been shown to be a valid reproducible index (Siddiqui et al. 2014). The index consists of two components, the Aesthetic Component and the Dental Health Component. The IOTN-AC is the subjective component of the index and consists of a set of 10 intraoral frontal photographs to be rated from 1 to 10, with 1 being the most attractive and 10 being the least attractive. The IOTN-AC provides a measurable, visual assessment regarding the patient’s perception of his or her presenting malocclusion and treatment needs (Siddiqui et al. 2014).
It is essential during the assessment to try to give dentists guidelines for when to proceed with treatment based on the severity of the need for treatment. A guideline for restorative dentistry (Falcon et al. 2001) identified that the most important priority for treatment (assessed by clinicians) had three levels; the highest priority was assigned to patients with inherited or developmental defects that justify complex care (e.g., clefts of the lip and palate). Since its initial development, this index has demonstrated some success in a difficult area.
When developing an index for treatment need for whitening, it is important to consider treatment need based on a wide variety of situations including congenital problems such as genetic defects of the teeth or congenital defects such as white or brown markings.
WHEN IS WHITENING NEEDED?
It is essential to clarify whether whitening treatment is needed for patients younger than 18. It would be helpful if an index of treatment need could be established to give further guidance as to who should be able to undergo tooth whitening without contravening the legislation.
According to the Whitening Group, the limit established by the current regulations makes it difficult to easily and cost-effectively treat patients; however, those with the following indications should be given priority:
1. Severe and moderate discoloration
2. Enamel conditions
3. White spots and small white marks
4. Brown, orange and yellow staining
5. Esthetic defects
6. Incisor discrepancies
7. Molar incisor hypoplasia
9. Hereditary factors e.g., amelogenesis imperfecta
10. Presence of a non-vital discolored anterior tooth
It is essential that treatment options be discussed with patients and their parents and that, where necessary, early intervention—whitening treatment to improve the color of the tooth—be undertaken after explaining all treatment options and the risks and benefits of treating patients younger than 18. All combinations of treatment need to be discussed, such as no treatment, combinations of whitening treatment, and whitening and esthetic or restorative treatment.
Various considerations come into play when evaluating the indications for treatment need:
• The shade of the discoloration (e.g., very dark shades—A4, C4, B4): such discoloration (indication 1) is subdivided into severe, moderate, and mild. Whitening treatment should be undertaken if the type of discoloration can be classified into the severe or moderate category, the child is aware of the discoloration, and the discoloration has an impact on the child’s life.
• The nature and extent of the discoloration.
• Whether the discoloration is spread uniformly on the tooth or whether there is mottling on the tooth.
• Whether the tooth is of normal color but with white marks, mottling, or flecks of white.
• The presence of brown discolorations on the labial surface of the tooth, which can be caused by trauma (previous bleeding into the tooth) or fluorosis markings. Occasionally the cause is unknown. Often it is the brown discoloration that is removed first when the whitening treatment commences and is the quickest to lighten. Sometimes it may take longer for the whitening treatment to remove the brown spot entirely. It may just fade to a pale-yellow mark. As the background color is lightened, the mark becomes less noticeable. Brown discolorations can be removed approximately 80% of the time (Haywood 2006). Only a few brown areas have required re-treatment in 1–3 years (Haywood 2006).
• The presence of white markings on the incisors and molar teeth. There is an increasing incidence of white spots on teeth (see Chapter 11). The white spots and markings can be extensive on the anterior teeth as well as the first molars. If this condition is present, early restorative intervention on the molar teeth is indicated as well as whitening treatment to reduce the effect of the white marks on the labial surface of the teeth.
• The impact of the discoloration on the child.
• Whether the discoloration is easily amenable to whitening or may require multiple treatment options such as whitening, enamel surface treatment such as Sylc treatment, sandblasting, microabrasion (12–26 microns of enamel are removed per 5-second application; Haywood 2006), or resin infiltration.
• Whether there is a single tooth discoloration such as a nonvital tooth as a result of trauma.
• Whether multiple discolorations are present throughout the whole dentition.
Patients with the conditions mentioned by the Working Group should have treatment with appropriate treatment planning according to the diagnosis.
• Discoloration caused by antibiotics.
• Intrinsic discoloration resulting from a child’s complex medical history; deposition of biliverdin or hemosiderin into the tooth.
• The administration of antibiotics at any age can have an impact on the developing dentition; when the teeth erupt they may have moderate discoloration. This may appear as banding, flecks, or patches. This can also manifest as localized or chronic hypoplasia (Wray and Welbury 2001 UK National Guidelines).
• Amelogenesis and dentinogenesis imperfecta (DGI).
• Childhood fevers and early antibiotic administration.
• Post-traumatic opacities in the permanent dentition.
• Idiopathic opacity.
• Chronologic hypomineralization or hypoplasia or any other opacity affecting the quality of life of the patient. This can occur because local or systemic factors that interfere with normal matrix formation cause enamel surface defects and irregularities called enamel hypoplasia. The changes can be mild or more extended, such as pitting on the surface. In primary teeth it is unusual to have hypoplasia visible, and this is more evident when the permanent dentition erupts (Dean et al. 2011).
• Hyperplasia of the primary dentition can appear as a halo or ring around the primary tooth.
WHITE SPOTS AND SMALL WHITE MARKS
• Some markings can appear as white lines that develop after the chronologic deposition of enamel—for example, amoxicillin defects. Sometimes the original white spots get more noticeable during the first few days of whitening (called the “splotchy stage”) (Haywood 2006). This is because during the whitening process the whitening gel penetrates the weakest part of the tooth first which is the white spot, as it represents a defect. This temporary lightening of white spot is due to the differently formed portions of enamel which are responding to the carbamide peroxide faster. Often this brief whitening can fade the spot entirely and no further adjunctive treatment may be necessary.
BROWN AND YELLOW STAINING
• Normally occurs from fluorosis on the teeth, enamel defects wherein the tooth has erupted with defective areas, or trauma in the primary dentition.
• Hypodontia, missing teeth, or teeth that are malformed on eruption—for example, saucer-shaped defects, ridges, and pitted and mottled teeth.
• Incisor discrepancies—a difference in the diameter of the central and lateral incisor teeth. The lateral incisors can often be peg shaped, so the esthetics become more of an issue.
MOLAR INCISOR HYPOPLASIA
• The impact on children is significant (see Chapter 11).
• Trauma followed by hemorrhage into the tooth during regenerative endodontic procedures.
• Trauma in the primary and secondary teeth.
• Discoloration resulting from endodontic therapy.
• See section on primary teeth, ages 2–5, later in the chapter.
Table 22.1 lists the five categories of whitening treatment need.
WHAT IS THE BEST AGE AT WHICH TO WHITEN TEETH FOR PATIENTS YOUNGER THAN 18?
It is important to assess the amount of discoloration and the cause before planning whitening treatment for a child younger than 18. It seems that the large pulps and the canals promote a good blood supply, which permits effective whitening for patients younger than 18 (Haywood 2006).
1. Discoloration: severe
2. Location of stain: uniform multiple dark distribution
3. Impact on child: severe
4. Whitening need: high
1. Discoloration: moderate
2. Location: even distribution
3. Impact on child: has an effect on the child
4. Whitening need: moderate
1. Discoloration: mild
2. Location: few anterior teeth
3. Impact on child: some impact
4. Whitening need: desirable; this will easily alleviate discoloration issues
1. Discoloration: isolated areas of discoloration
2. Location: random distribution across the tooth
3. Impact on child: moderate
4. Whitening need: advisable
1. Discoloration: mild discoloration or white spots
2. Location: few teeth or single tooth
3. Impact on child: no effect on the child
4. Whitening need: can be undertaken; may be desirable, but can wait until child is older than 18