As a work around the current legal confusion and regulations, there are a number of non-hydrogen peroxide systems (such as Hi Lite 2, Shofu, and Opalescence SP, Ultradent and Rapid White, Natural White, USA). These are based on a chlorate system and some are available as over-the counter systems for sale to the public in leading Chemists and Supermarkets in the UK.
All the above systems are manufactured as a viscous gel, and packaged in a syringe presentation. Recent changes have seen the gel being separated into a base material and activator. When squeezed through a special nozzle into a custom tray, the two components are evenly mixed and become active. This dual presentation has prolonged the shelf life from 12 – 18 months, to about 3 – 4 years.
Assessment & Information
It is very important that each patient is assessed prior to commencement of tooth whitening, either for at-home, or in-office tooth whitening. It is easy to produce a range of Patient-Information leaflets for a dental practice with modern computing technology. The more informed a person or potential client is, you will find your conversion from an inquiry about a product you offer into a sale will increase.
Where there are signs of caries, deep cervical abrasion areas, veneers or crowns, or filling materials, they should be warned that theee are potential problem areas, as caries and abrasion cavities may cause sensitivity. However, in the early research, and as noted by Professor Lynch and Dr Holmes, areas of active decay cease and will harden due to the action of the hydrogen peroxide.
Research has shown that it is impossible to predict which patient will have a degree of sensitivity, and how severe that sensitivity may be (Leonard Harword, Journal of Dental Restorations, 1996).
Some patients cannot tolerate even the weakest 10% carbamide gels. At times, it can be impossible to find a system that allows a patient to have whiter teeth by tooth whitening, without the need for local anaesthesia and in-office whitening. But dentists can reassure their patients that all symptoms will cease at the end of treatment (Haywood VB, et al, JPDA, 1994.).
Although periodontal disease and cervical lesions are listed as contra-indications, studies have shown an improvement in periodontal health whilst tooth whitening. As hydrogen peroxide will eliminate most of the bacteria that cause these disease processes, that is not an unexpected result. Pregnancy is often listed too. Manufacturers cannot test products on such a population group, but many pregnant ladies have benefited from whiter teeth.
It is important that as much information is given to your patients as possible. Each practice should have a range of practice leaflets about At-Home whitening, as well as Power Whitening. Each gives an idea of what the patient can realistically expect. It is important that the text does not give patients unrealistic expectations; otherwise complaints will follow unsuccessful whitening.
Patients should be warned that tooth whitening will not change the colour of existing fillings, porcelain veneers or crowns. “If fillings have already been placed, or are planned for the front of your mouth, we would advise you to carry out the whitening first, then your dental team can match the new restorations to the now lighter teeth.”
“You may feel increased sensitivity to foods and liquids during treatment. Some of our patients have reported transient discomfort during tooth whitening, such as gum soreness, tooth sensitivity, lip and tongue soreness and throat irritation. Most of these initial side effects resolve within 1-2 days once your whitening has been completed.”
Your brochures also should list the different whitening systems that are available, the current cost, and what the potential treatment time will be. Once armed with this information, it is easier for any patient to make an informed decision for themselves. Having said that, dentists are often asked what would they have done, if it were their mouth! When I was in practice in the late 1990's and up to 2004, since all my team and I have whitened our teeth with most of the systems, it is easy to talk from a position of knowledge. As a practitioner, I would encourage any dentist and their team members to whiten their own teeth if they want to sell cosmetic dental care. - And that also goes for orthodontics too. There is no point trying to actively sell a product into a market place if you are not a reflection in your belief in that product.
Some authors have suggested that full mouth x-rays should be taken routinely as part of this assessment. However, in the light of recent changes in the Ionising Regulations in the UK, where every x-ray has to be evaluated as to its clinical necessity, it is difficult to see how a charge of un-necessary exposure to radiation could be defended. Professor Edward Lynch and I do not recommend this invasive assessment. We have been using the DIAGNOdent (KaVo, Germany) in another study (Holmes, J et al, 2002) to assess the presence and severity of caries, and we feel that this technology gives the best guide to the presence of decay. This is supported by published research (Baysan, A et al, 2001).
A record of the colour and any morphological features of the teeth to be whitened should be made, and clinical photographs are very useful in this respect. It is sad to note that these can also prove very useful in any medico-legal dispute. It is possible to assess changes in colour with the DIAGNOdent and this research is not yet completed. However, initial results look very promising.
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