WHITENING, THERAPEUTIC ESTHETICS, AND ORAL HEALTH IMPROVEMENT

The Future

Linda Greenwall

INTRODUCTION

With the success of tooth whitening treatments, several health benefits have emerged that can improve patients’ oral health (Li and Greenwall 2013). Many people do not know that whitening treatment offers these oral health benefits, which can be harnessed for patients at different times of their lives. It is now essential to make use of these health benefits—to develop them further and create a program to improve patients’ dental health throughout their lives. The purpose of this chapter is to elaborate on the benefits of introducing a program of therapeutic esthetics as part of an oral health maintenance program and helping patients to gain health sustainability.

WHAT IS THERAPEUTIC ESTHETICS?

Therapeutic esthetics is the process of sustaining a patient’s oral health while improving and maintaining the esthetic health of their teeth. The whitening tray can be transformed to a therapeutic tray to deliver chemicals to help the patient achieve a sustained health gain throughout his or her life (see Figures 24.1 and 24.2 and Table 24.1). The trays are used for different purposes throughout a patient’s life (Table 24.2)—for instance, to treat high caries susceptibility at a young age (see Figure 24.3) or to treat dry mouth in an elderly patient who is taking multiple medications (see Figure 24.2A). The trays are worn to undertake a therapeutic use, be it to reduce caries, to reduce the high-risk classification of a caries exposure, to reduce root caries, or to assist with protecting the mouth during and after radiation treatment.

THE MATERIALS USED FOR TOOTH WHITENING

The two main tooth whitening materials are both derived from hydrogen peroxide. Hydrogen peroxide–only products are used as a day product in the tray. When the hydrogen peroxide product is placed in the tray, the material, once mixed with the saliva, releases water and oxygen, releasing effervescent bubbles. The oxygen penetrates into the enamel and dentin and reaches the pulp within 5–15 minutes. The flow of the material is multidirectional in three dimensions. The material also tracks into the gingival crevice and gingival pocket. The liberation of oxygen into the gingival crevice changes the bacterial environment to remove the Gram-negative bacteria, cleanse the pocket, and stimulate healing. All the oxygen is released within 1 hour, so there are no further benefits to using the material for longer than an hour. However, the day products will also improve the health of the gingivae.

Carbamide peroxide is a slower release material. The breakdown of carbamide peroxide is biexponential (Matis et al. 1999). After 2 hours, more than 50% of the active agent in carbamide peroxide whitening gel is available in whitening trays, and 10% is available after 10 hours (Matis et al. 1999). A greater-than-expected degradation occurs during the first 5 minutes.

The carbamide peroxide gels contains Carbopol, which allows the oxygen to be released slowly over a period of 8–10 hours. The carbamide peroxide material breaks down into urea and ammonia. The urea elevates the pH in the mouth. This stimulates healing. Reduction of caries is thought to occur by elevation of the pH above the level at which the caries process can occur, in addition to debridement of the teeth and improvement in gingival health. Carbamide peroxide heals the soft tissues and gingival areas. The effect of the oxygenating agents on the supragingival plaque has been equivocal, but recent data indicate that a stable agent that provides sustained active oxygen release is effective in controlling plaque (Gaffar et al. 1997).

The ammonia and carbon dioxide are released as well, but these are considered to be byproducts. Most of the home whitening materials also contain fluoride or potassium nitrate to act as soothers. These help to reduce the likelihood of sensitivity and reduce areas susceptible to caries. Within 5 minutes of the application of the material in the tray, the salivary pH is elevated for a period of 2 hours. The pH in the tray remains raised for 2 hours (Haywood 2007).

The most commonly used formulation is 10% carbamide peroxide; however, a lower concentration formulation, called Carbamide Plus, e.g., Novon Mild, has been developed. Its concentration of carbamide is 5%, and it is a three- component system. It contains hydrogen peroxide, urea, and sodium tripolyphosphate (Hyland et al. 2015). It is postulated that this increased whitening efficiency is the result of a marked increase in local pH on dilution, which destabilizes the hydrogen peroxide and expedites the whitening process.

BENEFITS OF TOOTH WHITENING

TEETH

•  Whitens and lightens the teeth.

•  Reduces stain build up on teeth.

•  Preserves tooth structure.

GINGIVAE

•  Reduces gingival inflammation.

•  Reduces gingival swelling.

•  Reduces plaque formation.

•  Reduces extrinsic stain buildup.

•  Reduces plaque adherence to teeth.

•  Reduces gingival bleeding.

•  Improves gingival index scores.

SOFT TISSUES

•  Improves health of soft tissue, healing of soft tissue lacerations.

•  Improves wound healing in the mouth.

ORAL HEALTH

•  Improves oral hygiene as the patient looks in the mirror to see the whiter teeth.

•  Whitens, brightens, and lightens teeth.

•  Reduces caries formation (Lee et al. 2005).

•  Reduces root caries formation (Haywood 2007).

•  Cleaner-feeling teeth as a result of improved oral hygiene.

PSYCHOLOGICAL AND RELATED EFFECTS

•  Improves patients’ self-esteem.

•  Improves patients’ sense of self-worth.

•  Patients smile more.

•  Patients become “walking advertisements” for the practice.

•  Patients help to market the practice as they show off their beautiful white smiles.

OTHER EFFECTS

•  The tooth whitening materials have antibacterial properties, which help to heal the mouth (Lazarchik and Haywood 2010) (see Figures 24.1, 24.2A, and 24.4A).

•  Reduction in oral malodor (DeVizio 2008).

•  Carbamide peroxide was originally used as an oral antiseptic.

HISTORY

Over the last century, hydrogen peroxide has been used as a treatment for reducing gingival inflammation. Initially patients were instructed to use hydrogen peroxide mouthwash on a toothbrush to help reduce gingival swelling and irritation. In 1968, an orthodontist, Bill Klausmier, advised his patients to use 3% hydrogen peroxide mouthwash in the retainers after completing orthodontic treatment. At the 6-month evaluation he noted that not only was the gingival inflammation reduced, but the teeth were significantly whiter. He developed and used this technique over the next 40 years and wrote a retrospective report about this technique. He wrote that in the 40 years of using the orthodontic retainer to apply the mouthwash to reduce the inflammation and also to whiten the teeth, nobody lost a tooth, needed a root canal, or damaged a tooth as a result of using this technique. Since then, the whitening gels have changed significantly and have become much thicker and more viscous, thus adhering to the trays more in order to deliver the materials.

MATERIALS THAT CAN BE USED IN THERAPEUTIC ESTHETICS

•  Carbamide peroxide

•  Hydrogen peroxide

•  Amorphous calcium phosphate (10% casein phosphopeptides and amorphous calcium phosphate [CPPACP] cream)

•  ACP plus fluoride (10% CPP-ACP cream plus 900 ppm fluoride)

•  Fluoride gel, paste, varnish

•  Corsodyl

•  Other medications

THE TRAY AS A VEHICLE FOR DELIVERING MATERIALS

Using the tray as a delivery vehicle, various chemicals can be placed to deliver sustained health benefits to the teeth over a chosen period of time (see Figure 24.4) according to the effectiveness of the material as it is released. The placement of the tray helps to keep the material in situ even if it may come into contact with the saliva. The tray can be made of flexible material such as Evacryl or a rigid material such as that used for Essix orthodontic retainers. The various materials are applied in the trays. The concept is that the tray remains in place overnight while the materials are soaking into the teeth or gingivae.

THE TRAY AS A DIAGNOSTIC AND ASSESSMENT TOOL

It is thought that in the future the whitening tray with the material inside will be used for further diagnostics and assessments, such as the salivary flow; pH of saliva; elevation of the PH; rate of remineralization; rate of decalcification; rate of repair of enamel, dentin, and root dentin; rate of whitening; rate of penetration of the whitening gel; and salivary and whitening kinetics. These whitening trays will have microchips inside to measure the rate of bruxism and tooth clenching and to gather further data, much like the wrist bands that are commonly used to measure fitness.

DESIGN OF THE TRAY FOR THERAPEUTIC USE

The tray design for therapeutic use can be varied and multipurpose depending on the material that is being placed in the tray. However, a scalloped tray around the papillae is a useful design. That way it does not impinge on the gingivae. The tray margins are cut just next to the gingival crevices. An orthodontic aligner can be used as a therapeutic tray as well as a retainer.

TRAY TYPES TO BE USED FOR THERAPEUTICS

A variety of tray designs can be used and modified for therapeutic use. The following is a list of trays that can be used for the purpose of therapeutics:

•  Aligners

•  Retainers such as an Essix retainer

•  Whitening tray

•  Specially designed tray similar to a whitening tray using a thicker strength material for extended wear time

USE OF THE THERAPEUTIC TRAYS THROUGHOUT THE PATIENT’S LIFE DEPENDING ON HEALTH NEED

There are times in a patient’s life when he or she may have additional health challenges. This puts the patient at risk for tooth decay, root decay, gingival inflammation, and dry mouth.

WHO CAN BENEFIT?

•  Those with special needs

•  Those at high risk for tooth decay

•  Patients with dry mouth

•  Elderly patients (Kelleher et al. 2011)

•  Chemotherapy patients

•  Patients undergoing radiation therapy

•  Patients with gingival and periodontal conditions

•  Patients whose teeth have white spots (see Figure 24.3)

•  Patients who are immunocompromised

•  Patients with eating disorders or acid reflux

•  Peri-implantitis patients (see Figure 24.4)

•  Post–periodontal surgery patients (e.g., crown lengthening, pocket reduction surgery).

ELDERLY PATIENTS

Many elderly patients take multiple medications that can cause dry mouth. This polypharmacy can result in reduced saliva. Some patients suck mints to relieve their dry mouth, which exacerbates the condition. Saliva is protective for the mouth, and the lack of saliva can cause the patient to be more susceptible to root decay and to have increased decay around the margins or crowns. Some frail elderly patients have poor oral hygiene owing to lack of motor skills because of arthritis or to caregivers who do not help the patient to brush the teeth. There is a direct link between poor oral hygiene and pneumonia. There is a direct effect of the oral bacteria on respiratory infection in the frail elderly (Scannapieco 1999). Haywood (2007) has shown that use of a nightly whitening tray with carbamide peroxide reduces root caries susceptibility. The whitening material kills caries bacteria and reduces plaque adherence to the teeth. Elderly patients who have difficulty holding a toothbrush may find it easier to apply the carbamide peroxide gel and place this in the mouth overnight. These effects will help patients achieve successful long-term health gains and improve their oral health. This chemotherapeutic approach enhances oral health.

SPECIAL NEEDS PATIENTS

In a study undertaken by Lazarchik and Haywood (2010), the authors found 10% carbamide peroxide delivered in a custom-fitted tray to be an effective treatment for caries in patients with compromised oral hygiene. Plaque suppression and caries control result from a carbamide peroxide–induced increase in salivary and plaque pH caused by carbamide peroxide’s urea component, and from possible antimicrobial action via physical debridement and the direct chemical effect of hydrogen peroxide.

PATIENTS WITH HIGH RISK FOR DECAY AND WHITE SPOT LESIONS

There are many people in this category who can be helped by the use of therapeutic trays, including patients who have poor oral hygiene and cannot maintain a clean mouth, patients with a high-sugar diet, and patients who are immunocompromised. Some patients who have eating disorders or who have reflux and acid regurgitation problems can also be helped by the use of a therapeutic tray. These patients would use carbamide peroxide gel to help reduce the plaque and also could place ACP into the tray to help elevate the pH further while restoring the oral environment to a neutral pH.

A concentration of 10% carbamide peroxide kills lactobacillus, one of the bacteria that causes tooth decay. Chlorhexidine (CHX) kills Streptococcus mutans bacteria, which are also responsible for tooth decay. A recent in vitro study testing the use of a 1.1% fluoride (NaF) toothpaste containing 5000 ppm, MI Paste, and MI Paste Plus noted that the sodium fluoride (NaF) was the most effective at reducing the white spots (Oliveira 2014) The results showed that a 1.1% NaF dentifrice (5000 ppm) demonstrated greater remineralization ability than the CPP-ACP topical tooth cream and that the addition of fluoride to its formulation seems to enhance remineralization. Saliva also has the ability to exert an important remineralization effect over time.

White spot lesions after orthodontic debanding are a common occurrence. These can be treated with a therapeutic esthetic approach by using either the therapeutic tray or the orthodontic retainer to apply various fluoride gels or ACP combinations (Heymann and Grauer 2013; see Table 24.3). In addition, patients with white spot lesions after orthodontic treatment may benefit from the use of MI Paste or MI Paste Plus in their orthodontic retainers to heal these lesions. A study showed that it may be more effective to combine this strategy with microabrasion to improve the fluorescence (i.e., the mineral content) of the enamel. A CPP-ACP paste alone does not significantly improve the fluorescence value of white spot lesions. Within the limitations of this in vitro study, microabrasion treatment with or without CPP-ACP improved the fluorescence and thus reduced white spot lesions.

Patients with small clinical root lesions can be given therapeutic trays to place ACP inside. Some patients may undertake whitening treatment first because whitening treatment using carbamide peroxide has been shown to reduce the appearance of root lesions. After the completion of the whitening treatment, the patient is instructed to use the trays for therapeutic purposes to deliver ACP with fluoride twice weekly (see Figure 24.6).

PATIENTS WITH PERI-IMPLANTITIS

The incidence of peri-implantitis is increasing as more implants are placed. There is a wide range of treatment options, most of which are unsatisfactory and involve improved oral hygiene techniques around the implant, the placement of CHX gel around the abutment connection, an intense course of antibiotics, removal of the implant, raising a flap for pocket reduction to salvage the implant, and using ultrasonics and air abrasion around the exposed threads and into the pocket. Sometimes the deterioration can be rapid with severe consequences involving bone loss around the implant. A simple maintenance strategy of placing 10% carbamide peroxide in a specially made therapeutic tray may be a sensible strategy to prevent this from occurring. The patient would wear this tray overnight, depending on the severity of the peri-implantitis. The wear schedule can vary depending on the severity of the peri-implantitis. A maintenance regimen could involve use of CHX once per week overnight, or daily nighttime placement of 10% carbamide peroxide or nightly use if there is suppurative exudate from the pocket. The problem with the standard treatment (i.e., CHX gel or mouthrinse) is that patients can develop a resistance to CHX over time. In addition, allergy to CHX has been reported in the literature to be increasing. For maintenance treatment, patients are shown in detail how to apply the gel and place the tray in the mouth with the gel in place. A specific wear routine will be given to the patient to improve maintenance (see Figure 24.5).

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