By Sandra Marcil, RDH, MS
Tooth whitening has become the most common cosmetic service provided by dental professionals today. Millions of Americans will spend more than $2 billion on tooth-whitening products this year, increasing 300 percent in the last five years.(1) Considering that our patient populations are made up of a wide variety of different socioeconomic levels, age groups, and ethnicities, including African-American, Caucasian, Hispanic, and Asian, our goal for each patient should be to create an attractive smile without overwhitening or creating artificial brightness. Although patients are looking for a smile that will give them a young, healthy appearance, it is important to discuss expectations and educate them about treatment options so acceptable results can be achieved for both the patient and clinician. Whitening systems such as the Pola line from SDI, Inc., includes take-home (Pola Day and Pola Night), in-office (Pola Office), jump-start (Pola Zing), and touch-up products (Pola Paint). These options give clinicians a wide range of services to offer to meet the varied needs of our patients and their desire to optimize their appearance.
The discussion about whitening should focus not only on expectations and compliance, but the benefits and possible considerations of these procedures as well. Considerations may include sensitivity and gingival irritation, both of which are reversible. Patients with known sensitivity will benefit from prewhitening hypersensitivity treatments with potassium nitrate and/or fluoride. Whitening systems that incorporate potassium nitrate and fluoride into the products are recommended to control the potential for discomfort associated with whitening. Research demonstrates that using potassium nitrate in whitening trays for 10 to 30 minutes prior to the whitening procedure results in a 97 percent reduction in sensitivity.(2) Soothe, (SDI, Limited, Australia) a sustained-release gel containing 6 percent potassium nitrate and 0.1 percent fluoride, can be applied before and/or after the whitening treatment. Since all patients have a saturation point or an ideal shade, realistic expectations and patient compliance are crucial for overall success.(3)
Additionally, the timing of the whitening process as part of a total treatment plan is critical to the ability of the dental professional to meet the needs of patients. The discussion of when to plan for whitening must take place prior to any cosmetic restorative procedure.
A whitening regimen should be based on desired outcome, time commitment, and prior experience with whitening. When the patient understands how the whitening process works and how important it is to be compliant, the outcome will always be better.
So, how fast is whitening? The strength of all whitening products — in-office, take-home, and over-the-counter (OTC) — is factored as a percentage of either hydrogen peroxide (HP) or carbamide peroxide (CP). Hydrogen peroxide is the active ingredient in all formulations. A 10 to 15 percent carbamide peroxide product breaks down to 3 to 5 percent hydrogen peroxide, a 3:1 ratio.(4) Peroxide based tooth whitening is a function of two factors: concentration and contact time. To produce the same degree of lightening, a whitening system can be a low concentration of either CP or HP for an extended time, or a high concentration of CP or HP for a shorter time.
Which is best? Because both types of systems produce the same whitening outcome, neither would be considered best from a treatment standpoint. Rather, consider which system fits best with the patient's lifestyle, needs, and finances, as well as the etiology of the stain, the individual patient's teeth, diet, and oral self-care habits.
In-office chairside whitening or "power bleaching" offers patients more immediate results and is a great practice-builder.(5) In-office treatments can be either HP or CP in concentrations typically ranging from 25 to 35 percent. Optional heat or light sources may be recommended as activators. Rubber dams or liquid dams are necessary to prevent gingival irritation and ingestion when using high concentrations. Follow-up take-home whitening for maintenance is generally considered necessary after in-office treatments.
Pola Office, a 35 percent HP with potassium nitrate, offers a quick and efficient single-use, 30-minute, in-office system. Use of a standard halogen or LED curing light is optional. Pola Zing, a 35 percent CP 30-minute in-office tray system, offers patients a jump-start before beginning a home treatment with a dentist-prescribed, take-home product.
Dentist-prescribed, take-home whitening systems can also contain either HP or CP in varying concentrations and are available as pastes or gels used in trays, paint-on products, strips, or rinses. Take-home products also contain thickening agents to provide viscosity and acidifiers to stabilize the peroxide in aqueous solutions. Pola Day and Pola Night systems offer a large choice of gel concentrations — 3, 7.5, and 9.5 percent HP and 10, 16, and 22 percent CP — giving the clinician multiple choices to treat a wide range of patient situations. Both of these products contain fluoride and high water content along with a desensitizing agent, which minimizes sensitivity and maximizes patient comfort.
Whitening is one of many esthetic options we can offer our patients. The procedure is simple, cost-effective, and noninvasive. For some patients, whitening may be the only esthetic treatment they need. However, for many patients, whitening is an initial step toward realizing the need for more advanced esthetic options to enhance their smile.
(1) American Academy of Cosmetic Dentistry (AACD). Cosmetic dentistry market research data. Available at: www.aacd.com/media/market_research_data.aspx. Accessed Oct. 22, 2006.
(2) Haywood VB. Taking the pain out of whitening. Dimensions. 2006; 4(9):32-33.
(3) Brogan D. The aesthetic smile: tooth whitening. JPH 2005; 14(3):9-13.
(4) Raposa K. The whitening generation: what you need to know to help your patients and your practice make the right decisions about tooth whitening. Access 2006; 20(8):25-28.
(5) Margeas R. New advances in tooth whitening and dental cleaning technology. Dental CE Digest; 3(5):13-20.
Sandra Marcil, RDH, MS, is an adjunct faculty member at the dental hygiene department at St.Petersburg College in Pinellas Park, Fla.