Download A Review of Tooth Whitening Services

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This course was
written for dentists,
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and assistants.
A Review of Tooth Whitening Services
A Peer-Reviewed Publication
Written by
Abstract
Educational Objectives
Utilization of tooth whitening products and services in
the U.S. and globally is very strong and shows no signs
of diminishing. The three primary methods of tooth
whitening include in-office, take-home and over the
counter whitening agents. The two major types of tooth
discoloration are intrinsic and extrinsic. Extrinsic stains are
easily removed during a prophylaxis. Extrinsic discoloration
can become intrinsic by migrating to the interior of the
tooth through pits, fissures and surface irregularities.
Peroxide containing whitening agents enhance the
appearance of teeth by addressing intrinsic stains. The
most common side effect of whitening procedures is
transient hypersensitivity. This course provides a review of
tooth whitening services and agents.
At the conclusion of this educational activity
participants will be able to:
1. Discuss the primary responsibilities of dental
professionals.
2. Describe the available tooth whitening agents
and their mechanism of action.
3. Discuss the potential benefits and side effects of
tooth whitening agents.
4. Describe the different types of tooth staining.
Author Profile
Author Disclosure
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Publication date: July 2015
Expiration date: June 2018
Supplement to PennWell Publications
PennWell designates this activity for 3 continuing educational credits.
Dental Board of California: Provider 4527, course registration number CA# 03“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”
The PennWell Corporation is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by the AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to
(10/31/2015) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services
discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had
any input into the development of course content.
Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required
fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products
or services discussed in this educational activity. Heather can be reached at [email protected]
Educational Disclaimer: Completing a single continuing education course does not provide enough information to result
in the participant being an expert in the field related to the course topic. It is a combination of many educational courses
and clinical experience that allows the participant to develop skills and expertise.
Image Authenticity Statement: The images in this educational activity have not been altered.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents
the most current information available from evidence based dentistry.
Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the
data and information contained in reference section. The research data is extensive and provides direct benefit to the patient
and improvements in oral health.
Registration: The cost of this CE course is $59.00 for 3 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
Educational Objectives
At the conclusion of this educational activity participants will
be able to:
1. Discuss the primary responsibilities of dental
professionals.
2. Describe the available tooth whitening agents and their
mechanism of action.
3. Discuss the potential benefits and side effects of tooth
whitening agents.
4. Describe the different types of tooth staining.
“The ADA recommends that if you choose to use a bleaching product, you should only do so after consultation with a
dentist. This is especially important for patients with many
fillings, crowns, and extremely dark stains. A thorough oral
examination, performed by a licensed dentist, is essential to
determine if bleaching is an appropriate course of treatment.
The dentist and patient together can determine the most appropriate treatment. The dentist may then advise the patient
and supervise the use of bleaching agents within the context of
a comprehensive, appropriately sequenced treatment plan.”
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Abstract
Utilization of tooth whitening products and services in the U.S.
and globally is very strong and shows no signs of diminishing.
The three primary methods of tooth whitening include in-office, take-home and over the counter whitening agents. The two
major types of tooth discoloration are intrinsic and extrinsic. Extrinsic stains are easily removed during a prophylaxis. Extrinsic
discoloration can become intrinsic by migrating to the interior of
the tooth through pits, fissures and surface irregularities. Peroxide containing whitening agents enhance the appearance of teeth
by addressing intrinsic stains. The most common side effect of
whitening procedures is transient hypersensitivity. This course
provides a review of tooth whitening services and agents.
Introduction
Esthetic dental services have developed over a relatively short
period of time and the demand for these services is very high.
Recent estimates indicate that Americans are spending over 2
billion dollars annually on the various types of tooth whitening
products and services available. The terms whitening and bleaching are used interchangeably by both the dental profession and
the lay public. It may be worthwhile to emphasize to patients that
bleaching does not refer to the type of bleach used in the laundry.
Whitening agents are not drugs and as such, are not regulated by
the Food and Drug Administration. It should be appreciated that
not all patients who desire whiter teeth are good candidates. Oral
and systemic contraindications preclude some patients from these
services. Patient expectations should also be addressed along with
the potential side effects, most notably hypersensitivity. Esthetic
procedures including tooth whitening must be considered within
the context of the patient’s oral and general health, which are the
primary responsibilities of dentists, dental hygienists and other
dental professionals. Diagnosis and management of disease is the
first and most important priority of dental clinicians. It would be
inappropriate to provide tooth whitening services or any other
cosmetic dental procedure to a patient with periodontal disease,
caries or mucosal lesions, among many others.
The ADA Position Statement on Tooth Whitening
In April 2012 the ADA Council on Scientific Affairs adopted
its; “Statement on the Safety and Effectiveness of Tooth Whitening Products”. The summary of the statement is as follows:
Thorough Oral Exam and an Appropriately
Sequenced Treatment Plan
The ADA recommends the provision of other esthetic dental
services as well. Regarding porcelain veneers, the organization
states; “There’s no reason to put up with gaps in your teeth, or
with teeth that are stained, badly shaped or crooked. Today a
veneer placed on top of your teeth can correct nature’s mistake
or the results of an injury and help you have a beautiful smile.”
The most impactful aspect of the ADA’s whitening position
statement is that use of bleaching agents are to be undertaken
within the context of an appropriately sequenced treatment plan.
Appropriate sequence clearly means prioritizing patient needs,
with disease and function first, and esthetic procedures provided
during or after disease management and restoration of proper function. The ADA also notes the need for a thorough oral examination
by a licensed dentist to determine if tooth whitening treatment is
appropriate for the patient. Providing veneers, porcelain crowns,
tooth whitening etc. to a patient with uncontrolled periodontitis
would be similar to a physician providing Botox® injections to a patient with uncontrolled hypertension, diabetes or atherosclerosis,
among others. This is obviously the reason why the ADA cautions
against the use of whitening services without consideration of the
patient’s oral and overall health. Failure to examine, treatment plan
and address the highest priority dental needs prior to providing
cosmetic procedures would be ethically questionable. In certain
circumstances necessary and elective procedures can be provided
simultaneously, depending on the specific dental needs. If a patient has a limited number of small to moderate carious lesions and
healthy gingiva, providing in-office whitening or impressions for
take-home whitening can be provided when the carious lesions are
treated. If a patient has xerostomia, the etiology should be determined and the condition should be addressed with an antioxidant
gel or an enzymatic oral rinse, among others.
Periodontal disease is a category unto itself. Gum disease is
a bacterial infection, with inflammation-driven damage to the
hard and soft tissue which must be controlled prior to undertaking a cosmetic treatment plan of any kind. This may take an
extended period of time. The overarching reason for addressing
and controlling periodontal disease, high caries rate, xerostomia
or any other oral pathology or condition prior to providing esthetic dental services is because the same problems will continue
or recur after the desired cosmetic result is achieved.
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It is completely ethical to provide tooth whitening or other
cosmetic procedures when undertaken in a properly sequenced
treatment plan. Contributory medical conditions such as diabetes, chronic infections, autoimmune disorders and chronic inflammatory conditions are addressed first. Referral to a dental
specialist or physician may be necessary. The patient’s biofilm
control regimen should also be thoroughly evaluated since the
most common oral diseases and conditions are directly linked
to the oral bacterial load. Recommendations for the appropriate
biofilm control devices such as power toothbrushes, antimicrobial rinses and interdental cleaning devices should be provided
not only to facilitate optimal oral and general health, but to
protect the patient’s financial investment in their appearance.
Intrinsic Stains
When extrinsic stains migrate below the surface they become
intrinsic stains and can no longer be removed by mechanical
means. Intrinsic molecules that cause discoloration are organic
pigments incorporated into enamel during tooth formation.
The visual effects of intrinsic tooth color are associated with
the absorption and reflection of light by the enamel and dentin
with the dentin playing the primary role in determining overall
tooth color. The natural off-white hue of enamel is modified
by the yellow/brown shades of dentin, together determining
the normal color of an individual’s teeth. Discoloration can also
be caused by trauma, tetracycline and a number of metabolic
diseases and other systemic factors. Postnatal infections such
as chicken pox, streptococcal infections and scarlet fever can
result in tooth discoloration as well. With advancing age, an
individual’s teeth commonly take on a generalized yellow or
brown color. This occurs as a result of thinning of the enamel,
thus revealing more of the darker underlying dentin. Additionally, over time, the dentin becomes darker from the formation
of secondary dentin in response to restorations and normal
physiologic processes.
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Extrinsic Stains
The superficial or extrinsic coloration of an individual’s teeth
is associated with stain that accumulates on the surface of the
teeth from food and beverages, which can seep into the cracks,
pits and flaws in the enamel. Seepage can also occur between the
enamel rods in some cases. Some individuals seem to be more
susceptible to extrinsic staining due to enamel surface morphology, salivary proteins, diet, tobacco usage and the efficacy
of the home care. High levels of extrinsic staining are caused by
polyphenolic compounds found in food and beverages such as
red wine, darkly brewed tea, chocolate, coffee, grapes, pomegranate, spinach and plums, among others. Superficial stain
accumulation occurs as a result of the attraction between the
negatively charged salivary pellicle and the positively charged
food/beverage molecules. (Figures 1, 2) Extrinsic stain is substantially removed by abrasives in toothpaste and prophy paste.
Figure 3. Discoloration of central incisor from trauma
Figure 1. Staining from chlorhexidine rinse
Figure 4. Discoloration from trauma
Figure 2. Extrinsic stain
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Figure 5. Flourosis staining
Figure 9. Staining from postnatal infection
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Figure 6. Flourosis staining
Figure 7. Tetracycline staining
Enamel is semitranslucent and the underlying dentin color
and other colored substances beneath the enamel affects the
overall color of the teeth. Tooth color is caused by a variety of
factors including the influence of genetics, drugs and medication taken by the mother while pregnant or the child during
tooth development such as tetracycline. Environmental factors
such as excess fluoride intake and maternal infections also
influence tooth color. An individual’s genetic makeup is the
primary determinant of tooth color. Some people’s teeth have
a blue-gray base color, others more yellow-brown. When it
comes to tooth whitening, yellow and brown base colored teeth
whiten faster than blue-gray teeth.
The color molecules are comprised of groups of atoms that are
held together by bonding forces. Some of these bonding forces
themselves absorb and reflect light. The absorption of light makes
the object, in this case the teeth, appear darker and light reflection gives the appearance of color. These absorbing and reflecting
bonds are called chromophores and they are all around us. Everything we see, and the colors we observe and due to chromophores.
Peroxide based whitening agents work by breaking the chromophore bonds, bringing out the natural whiteness of the teeth.
Mechanism of Action of Peroxide Tooth
Whitening Agents
Figure 8. Tetracycline staining
Intrinsic staining is removed by chemical means, primarily different forms of peroxide. Typically used whitening agents are
hydrogen peroxide or carbamide peroxide-containing whitening
gels, liquids, strips etc. Carbamide peroxide is broken down into
hydrogen peroxide and urea upon dissolution in water or saliva.
Peroxide based bleaching products diffuse into the tooth and react with the color molecules. The mechanism by which peroxide
compounds lightens the color of the teeth involves the chemical composition of the intrinsic stain. Upon application of the
bleaching gel, hydrogen peroxide (H2O2) breaks down into H2O
and a free reactive oxygen species. These hydrogen peroxide
breakdown products attach to the stained portions of the teeth
which have the chromophore bonds. The free reactive oxygen
species break the double chromophore bonds into single bonds.
The single bonded carbon atoms produce colorless molecules
bringing out the natural whiteness of the teeth. (Figure 10)
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Figure 10. Mechanism of Action: Hydrogen Peroxide (H 2O 2)
Figure 12. Curing dam
H 2O 2
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Free
Radical
Generated
Figure 13. Application of whitening gel
Carbon Double
Bond
Tooth Whitening Treatments
Chemical tooth whitening can be performed in-office or at
home, using products dispensed in the office or over the counter (OTC). Professionally provided and consumer take-home
bleaching agents are supplied as pastes or gels that are used in
trays, strips, rinses or paint-on liquids. The whitening agents
typically used with take-home products are carbamide peroxide
or hydrogen peroxide. The concentration of the whitening agent
ranges between 10-35% depending on the manufacturer.
The same agents are used for in-office whitening and the concentrations can range up to 40% hydrogen peroxide. The oral
tissue must be carefully isolated to prevent soft tissue irritation
and ingestion. The most common method of isolation is by using
paint-on or rubber dams. Protective eyewear must also be used
by patients undergoing in-office bleaching, as is the case anytime
a curing light is used and aerosols are created. An example of the
steps involved in in-office whitening are shown in figures 11-17.
Figure 11. Application of paint-on dam for gingival protection
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Figure 14. Completing application of whitening gel
Figure 15. Whitening gel removal with air/water syringe after recommended period of time
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Figure 16. Removal of dam
Figure 20. Placement of the tray in the upper arch
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Figure 17. Final results demonstrating significant whitening
Figure 18. Before and after chemically activated in-office tooth whitening.
Take home whitening involves a simple process as shown
in figures 19 and 20. The patient should receive instructions
to ensure safety which include whitening only for the specified
period of time once per day and to avoid overfilling the trays.
Figure 19. Application of whitening gel to facial surface of tray
In-office whitening treatments provide immediate results
while take-home products can take days or weeks to provide
the same result. In-office whitening procedures commonly
employ the use of chemically activated whitening systems,
while other systems are light activated. Tooth whitening due to
dehydration can occur in some cases of light activated in-office
whitening. In such cases rebound can occur making the teeth
look darker than they looked immediately following the whitening procedure, potentially leading to patient dissatisfaction.
The peroxide concentration of take home bleaching agents are
generally lower than in-office whitening agents. This is due to
the lack of professional application and supervision with agents
applied by the patient.
There are advantages and disadvantages to in-office and
take-home whitening treatments, just as there are for virtually
any situation with multiple options. The primary advantage of
in-office whitening is the same day results. For some patients
this may be the best option due to a personal or social event such
as a wedding or reunion, receiving an award or starting a new
job in the near future. Another consideration for many patients
is cost. In-office treatment is commonly more expensive than
take-home whitening. Compliance is another consideration.
Patients may opt for in-office whitening, or the clinician may
recommend in-office treatment if they know from past experience that compliance is an issue in general. Patients who have
difficulty taking all doses of prescription medication or those
who have had past compliance issues with take-home whitening may be good candidates for in-office treatment.
The advantages of in-office whitening are the same day
results and the lack of compliance issues. The cost may be
perceived to be a disadvantage by some patients. The primary
advantage of take-home preparations is the lower cost. Disadvantages of take-home treatments include the longer time frame
to achieve the end results and the potential for non-compliance.
Tooth Whitening Contraindications
Patient selection is critical when tooth whitening is being
considered by the patient or recommended by the clinician.
Women who are pregnant or nursing should avoid all whitening procedures and products. There is no research demonstrating safety during pregnancy or while nursing. Children should
be carefully screened. Tooth whitening for patients below the
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age of 15 should only be provided with careful consideration.
Patients in this age category should only be treated under
dental professional supervision. Patients with gum disease,
especially periodontitis, should defer esthetic procedures of all
types, including tooth bleaching, until the disease is controlled.
There is some evidence that peroxide compounds kill bacteria
and may thereby be beneficial to the gingiva, but tooth whitening should never be considered or cited as a viable primary or
adjunctive treatment option for periodontal disease. Patients
with significant restorative needs should have these addressed
prior to whitening the teeth. Other contraindications may
include exposed root surfaces, xerostomia or a history of hypersensitivity. Individuals with dental restorations involving the
facial surfaces of teeth in the esthetic zone must be advised that
the restorations will not respond to the whitening agents. This
includes composite restorations, hybrid restorations, crowns,
veneers, bridgework or any other dental restorative material.
Patients should be advised that whitening procedures will only
have an effect on natural tooth surfaces and that restorations
may need to be replaced after whitening the teeth.
heat, acids, pressure and chemicals, among others, to the nerve
endings in the pulp. The basis of this theory is that the fluid
filled dentinal tubules are open to the oral cavity at the dentinal
surface as well as within the pulp.
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Issues Associated with Tooth Whitening
Potential side effects of tooth whitening are changes to the
properties of dental restorations. There is significant variability
of whitening agents including concentration, duration of contact and pH, among others. Some studies have shown no effects
on dental restorations. Other studies have shown an increase in
surface roughness and decrease in hardness of porcelain restorations. Other studies have shown deleterious effects to glass
ionomer cements. Numerous studies have demonstrated a potential for changes to composite restorations. Still other studies
have shown changes to color, surface hardness and roughness,
staining susceptibility, microleakage and elution, in which the
composite material washes out of the restorations. The large
number of variables and inconsistent study results prevents definitive conclusions regarding the effect of whitening agents on
restorations at this time. However, caution should be advised
with all tooth whitening systems due to the potential negative
effects on dental restorations and materials from improper use.
Survey research has indicated that the most frequently reported issue with whitening treatment is sensitivity, followed
by soft tissue irritation. Gingival, lingual, palatal or mucosal
irritation is caused by exposure of the tissue to the bleaching
agent. Ill-fitting or overfilled take-home trays can result in tissue exposure and irritation. Improperly applied paint-on dam
can expose the tissue to damage during in-office whitening.
Tooth sensitivity has been an issue since whitening materials were first introduced. The most widely accepted theory
explaining the mechanism of tooth sensitivity is Brannstrom’s
hydrodynamic theory, first described in 1966. Brannstrom’s theory indicates that stimuli are transmitted to the pulp from fluid
movement in the dentinal tubules. The inward and outward flow
of fluid acts as the medium conveying stimuli including cold,
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Figure 21. Brannstrom’s hydrodynamic theory.
Fluid travels through tubule
and excites nerve
Stimuli on exposed
dentin cause fluid
movement in tubule
Sensitivity is subjective and transient with symptoms usually disappearing in a matter of hours or a few days.
Some whitening agents will dehydrate the teeth, particularly
if they are anhydrous, and this can also contribute to sensitivity.
The dehydration can make the teeth appear whiter and as the
tooth rehydrates in a short period of time the whiter color dissipates. This phenomenon can easily be mistaken for a transient,
short duration whitening result, when in reality it was due to
dehydration of the tooth. Rebound of whitening effect can also
occur in which the pre-treatment discoloration of the teeth
reappears. Hydrogen peroxide changes the color of the stain
molecules, rather than actually removing them. Over time, the
stained appearance can reappear.
Prior to whitening treatment, a thorough conversation
with the patient especially those who experience sensitivity to
temperature variation. Discussing the potential for sensitivity
to patients prior to undertaking treatment will help the patient make an informed decision. Thorough documentation of
pre-op conversations is important as well. The manufacturers
of whitening materials have addressed sensitivity by adding
different compounds to the bleaching agent. These include
amorphous calcium phosphate, potassium nitrate and fluoride,
among others. Some in-office light activated whitening equipment have variable intensity lights to help manage sensitivity.
Addressing Patient Expectations
It is critically important to discuss each patient’s expectations
prior to undertaking whitening treatment. A thorough clinical
and radiographic examination must precede esthetic treatment.
Patients who are pregnant, have xerostomia, exposed root
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surfaces or those with generalized thermal sensitivity need to
be informed that they are not candidates for tooth whitening.
Patients who are allergic to peroxides must be excluded as well.
Systemic contraindications include patients with asthma or
other respiratory conditions, uncontrolled diabetes or cancer.
Patients with restorations in the esthetic zone need to be informed that they may need to be redone to match the shade of
the teeth after whitening. Patient’s expectations should also be
discussed if the teeth have bands of discoloration or very dark
teeth prior to whitening. Once it has been determined that a
patient is a good candidate for whitening and all other dental
needs have been addressed, a discussion of the potential side effects should occur. Among the topics that must be discussed is
the possibility for hypersensitivity, soft tissue inflammation or
other side effects. The final shade that will be achieved cannot
be guaranteed without risking patient dissatisfaction. The potential for rebound of the discoloration must also be mentioned,
as well as the possibility of non-uniform results. Some patient’s
teeth have a streaky or blotchy appearance after whitening. This
usually self corrects in a short period of time. In some instances,
the non-uniform results are due to dehydration which correct
in a few hours or days. The need for thorough documentation
cannot be overstated. The patient notes should include the
essential nature of the dialogue, potential contraindications,
expectations, etiology of the discoloration and the patient’s
level of understanding of the potential side effects. Documentation should also indicate that the patient had the opportunity
to ask all of their questions and they understood the answers
provided. The records should be similar to an informed consent
document.
Ideally at this point the patient selects in-office or takehome whitening. Prior to undertaking whitening treatment a
pre-op shade must be selected, having the patient participate
in the initial shade selection. For patients who select take-home
whitening, they should be instructed to whiten until the desired
shade is achieved, rather than for a pre-determined number
of days. Appearance in general is subjective and the patient’s
opinion of what constitutes an ideal result should be discussed
in advance. Choosing and endpoint for treatment can provide a
goal for the patient.
and public speakers. Among the reasons cited by individuals
who whiten their teeth are self-esteem and confidence in social
and business situations. Tooth whitening is the number one
cosmetic procedure because it’s the most affordable way to
significantly improve one’s appearance.
Further developments in whitening procedures and materials will continue in the future. Improvements in the predictability of the results, outcomes and reductions is side effects
will benefit our patients and our practices.
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Conclusion
When undertaken with careful consideration and proper
sequencing of treatment, whitening can have a very positive
outcome for the patient. Patients who are reluctant to smile in
general, in photographs, in social or business situations due
to the appearance of their teeth can experience a life changing
outcome from tooth whitening. There are many reasons why
people whiten their teeth but the underlying motivation is
the desire for a better looking smile. There are many reasons
why people want to enhance their appearance including career
advancement. The obvious examples include models, television and movie actors. Others include corporate executives
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Papathanasiou A, et al. Clinical evaluation of a 35% hydrogen peroxide in-office
whitening system. Comp 2002;23:335–346.
Leonard RH Jr, Bentley C, Eagle JC, et al. Nightguard vital bleaching: a longterm study on efficacy, shade retention, side effects, and patients’ perceptions. J
Esthet Restor Dent. 2001;13(6):357–369.
Brunton PA, Ellwood R, Davies R. A six-month study of two self-applied tooth
whitening products containing carbamide peroxide. Oper Dent. 2004;29(6):623–
626.
Basting RT, Rodrigues AL Jr, Serra MC. The effect of 10% carbamide peroxide,
carbopol and/or glycerin on enamel and dentin microhardness. Oper Dent.
2005;30(5):608–616.
Cavalli V, Arrais CA, Giannini M, Ambrosano GM. High-concentrated
carbamide peroxide bleaching agents’ effects on enamel surface. J Oral Rehabil.
2004;31(2):155–159.
Spalding M, Taveira LA, de Assis GF. Scanning electron microscopy study of
dental enamel surface exposed to 35% hydrogen peroxide: alone, with saliva,
and with 10% carbamide peroxide. J Esthet Restor Dent. 2003;15(3):154–164.
Basting RT, Rodrigues AL Jr, Serra MC. The effects of seven carbamide
peroxide bleaching agents on enamel microhardness over time. J Am Dent
Assoc. 2003;134(10):1335–1342.
Turker SB, Biskin T. The effect of bleaching agents on the microhardness of
dental aesthetic restorative materials. J Oral Rehabil. 2002;29(7):657-61.
Taher NM. The effect of bleaching agents on the surface hardness of tooth
colored restorative materials. J Contemp Dent Pract. 2005;6(2):18-26.
Yu H, Pan X, Lin Y, Li Q, Hussain M, Wang Y. Effects of carbamide peroxide
on the staining susceptibility of tooth-colored restorative materials. Oper Dent.
2009;34(1):72-82.
Li Q, Yu H, Wang Y. Colour and surface analysis of carbamide peroxide bleaching
effects on the dental restorative materials in situ. J Dent. 2009;37(5):348-56.
Epub 2009 Feb 8.
Hubbezoglu i, Akaoglu B, Dogan A, Keskin S, Bolayir G, Özçelik S, et al. Effect
of bleaching on color change and refractive index of dental composite resins.
Dent Mater J. 2008;27(1):105-16
Wattanapayungkul P, Yap AUJ, Chooi KW, Lee MFLA, Selamat RS, Zhou RD.
The effect of home bleaching agents on the surface roughness of tooth-colored
restoratives with time. Oper Dent. 2004;29(4):398-403.
Moraes RR, Marimon JL, Schneider LF, Correr Sobrinho L, Camacho GB,
Bueno M. Carbamide peroxide bleaching agents: effects on surface roughness
of enamel, composite and porcelain. Clin Oral Investig. 2006;10(1):23-8. Epub
2005 Nov 16.
Justino LM, Tames DR, Demarco FF. In situ and in vitro effects of bleaching
with carbamide peroxide on human enamel. Oper Dent. 2004;29(2):219–225.
Villalta P, Lu H, Okte Z, Garcia-Godoy F, Powers JM. Effects of staining
and bleaching on color change of dental composite resins. J Prosthet Dent.
2006;95(2):137-42.
Leonard RH Jr, Garland GE, Eagle JC, Caplan DJ. Safety issues when
using a 16% carbamide peroxide whitening solution. J Esthet Restor Dent.
2002;14(6):358–367.
Türkün LS, Türkün M. Effect of bleaching and repolishing procedures on coffee
and tea stain removal from three anterior composite veneering materials. J Esthet
Restor Dent. 2004;16(5):290-302.
Strassler HE. What’s up with whitening? An update on professionally dispensed
vital bleaching. ADTS. www.ineedce.com. Accessed November 2006.
Christensen GJ, et al. Home use bleaching study-1995. CRA Newsletter
1995;19(10):1.
Matis BA, Gaiao U, Blackman D, et al. In vivo degradation of bleaching gel used
in whitening teeth. J Am Dent Assoc. 1999;130(2):227–235.
Nathoo S, et al. Comparative seven-day clinical evaluation of two tooth
whitening products.
Strassler HE. What’s up with whitening? An update on professionally dispensed
vital bleaching. ADTS. www.ineedce.com. Accessed November 2006.
Compend Contin Educ Dent. 2001;22(7):599-604,606).
Giniger, M, Bastini, T, Olsen, B. Assessment of enamel surface effect caused
by aqueous cleaning technology. J Dent Res, abstract 91293, accepted for
publication
Spaid, M, Giniger, M. Effect of adjunctive universal whitening enhancer on
enamel and dentin. IADR 2006; Abstract 1665.
Sulieman M. An overview of tooth discoloration: extrinsic, intrinsic and
internalized stains. Dent Update. 2005 Oct;(8):463-4, 466-8, 471.
Kurthy R. Dentaltown. Why we see problems with teeth whitening: The science
of whitening. Part 1. 2012 Nov:92-99.
Margeas, R. New advances in tooth whitening and dental cleaning technology.
www.ineedce.com/ courses/1464/PDF/NewAdvancesinTooth.pdf.
Kossatz S, et al. Tooth sensitivity and bleaching effectiveness associated with
use of a calciumcontaining in-office bleaching gel. J Am Dent Assoc. 2012
Dec;143(12):e81-7.
Basting R, et al. Clinical Comparative Study ofthe Effectiveness of and Tooth
Sensitivity to 10% and 20% Carbamide Peroxide Home-use and 35% and 38%
Hydrogen Peroxide In-office Bleaching Materials Containing Desensitizing
Agents. Oper Dent. 2012 Sep-Oct;37(5):464-73. doi: 10.2341/11-337-C. Epub
2012 May 18.
He LB, et al. The effects of light on bleaching and tooth sensitivity during inoffice vital bleaching: a systematic review and meta-analysis. J Dent. 2012
Aug;40(8):644-53. doi: 10.1016/j.jdent.2012.04.010. Epub 2012 Apr 21.
Reference: www.nlm.nih.gov/medlineplus/ency/ article/003065.htm.
Dawson PF, et al. A clinical study comparing the efficacy and sensitivity of home
vs combined whitening. Oper Dent. 2011 Sep-Oct;36(5):460-6. doi: 10.2341/10159-C. Epub 2011 Aug 22).
Goldberg M, et al. Tooth bleaching treatments: A review: Association Dentaire
Francaise, Paris, 2005.
Author Profile
Klukowska M. Analysis of surface stains treated with whitening formulations.
81st General Session of the International Association for Dental Research. 2003.
Duchner H, et al. Bleaching effects on subsurface enamel and coronal dentin.
IADR/AADR/CADR. 82nd General Session. 2004;(March 10-13).
Ontiveras, JC, Paravina RD. Color change of www.ineedce.com 11 vital teeth
exposed to bleaching performed with and without supplementary light. J Dent.
2009 Nov;37(11):840-7. doi: 10.1016/j.jdent.2009.06.015. Epub 2009 Jun 30.
Ontiveros JC. In-office vital bleaching with adjunct light. Dent Clin North Am.
2011 Apr;55(2):241-53, viii. doi: 10.1016/j.cden.2011.01.002.
Leonard RH, et al. Use of different concentrations of carbamide peroxide for
bleaching teeth: an in vitro study. Quintessence Int. 1998;29:503-507.
Author Disclosure
Matis BA, et al. Clinical evaluation of bleaching agents of different concentrations.
www.ineedce.com
9
Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online
purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An
immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed
anytime in the future by returning to the site, sign in and return to your Archives Page.
Questions
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1.The color of and individual’s teeth results
from:
11. Which of the H2O2 breakdown products
breaks carbon to carbon double bonds?
20. Patient documentation should include:
2.Which of the following can increase the
discoloration of teeth?
12. Carbamide peroxide breaks down into:
21. Consumption of foods rich in which of the
following increases extrinsic staining?
a. Intrinsic and extrinsic color molecules
b. Intrinsic and interior color molecules
c. Extrinsic and exterior color molecules
d. Superficial stains only
a.Trauma
b. Surface irregularities
c. Enamel pits and fissures
d. All of the above
3.The American Dental Association’s
position on tooth whitening states:
a. Tooth whitening is appropriate for everyone with
dark teeth
b. Tooth whitening can be undertaken after a thorough
exam
c. Tooth whitening can be undertaken as part of a
properly sequenced treatment plan
d. Both b and c
4.The most common side effects of tooth
whitening are:
a. Sensitivity and periodontitis
b. Sensitivity and gingivitis
c. Sensitivity and soft tissue irritation
d. Sensitivity and caries
5.Causes of intrinsic staining include;
a. Frequent consumption of darkly brewed tea
b.Trauma
c.Medications
d. Both b and c
6.Tooth sensitivity association whitening is:
a.Permanent
b. Always severe
c.Transient
d. None of the above
7.Contraindications to tooth whitening
include all of the following except:
a. Active periodontal disease
b. Orthodontic treatment
c. 18 years of age
d.Pregnancy
8.Which of the following is true regarding
tooth coloration?
a. Intrinsic stains can become extrinsic stains
b. Extrinsic stains can become intrinsic stains
c. Extrinsic stains are the result of organic pigments
incorporation during tooth formation
d. None of the above
9.Which of the following is true regarding
the FDA’s position on tooth whitening
procedures?
a. FDA approves whitening procedures
b. FDA regulates whitening procedures
c. FDA has not taken a position on whitening
procedures
d. None of the above
10. Which of the following is generated by
H2O2?
a. Free radicals
b.H2O
c. Both a and b
d. None of the above
a.H2O
b. The unpaired oxygen free radical
c. Both a and b
d. None of the above
a. Hydrogen peroxide and urea
b. Hydrogen peroxide and H2O
c. Hydrogen peroxide and oxygen
d. Free radicals
13. Which of the following is true regarding
managing tooth patient expectations with
tooth whitening procedures?
a. Discussions should be undertaken during the
treatment
b. Potential side effects should be addressed when they
occur
c. The final shade of the teeth can be guaranteed prior
to whitening
d. None of the above
14. Brannstrom’s hydrodynamic theory
indicates;
a. Static fluid in the dentinal tubules increases
sensitivity
b. Movement of particles in the dentinal tubules
increases sensitivity
c. Movement of fluid in the enamel increases
sensitivity
d. None of the above
15. Which of the following conditions may be
contraindications for tooth whitening?
a.Xerostomia
b. Previous thermal sensitivity
c. Compliance issues
d. All of the above
16. Which of the following is true regarding
advantages and disadvantages of in-office
and take-home tooth whitening?
a. The primary advantage of take-home whitening is
the same day results
b. The primary advantage of in-office whitening is the
same day results
c. The primary disadvantage of take-home whitening
is the cost
d. The primary disadvantage of in-office whitening is
compliance
17. Materials used to reduce sensitivity include
all of the following except;
a. Amorphous calcium phosphate
b. Potassium nitrate
c. Amorphous calcium nitrate
d. Variable light intensity
18. Gingival, lingual, palatal or mucosal
irritation is caused by:
a. Exposure of the tissue to the bleaching agent
b. Ill-fitting or overfilled take-home trays
c. Improperly applied paint-on dam
d. All of the above
19. Studies have shown changes in composite
restorations after tooth whitening
including:
a.Elution
b. Improved surface hardness
c. Reduced surface roughness
d. Increased longevity of the restoration
a. The essential nature of the dialogue between
clinician and patient
b. Potential contraindications
c. Patient expectations
d. All of the above
a. Alkaline compounds
b.Polyphenols
c. Acidic compounds
d. All of the above
22. It is ethical to provide tooth whitening
services:
a. When undertaken as part of a properly sequenced
treatment plan
b. Without a radiographic examination
c. Without a clinical examination
d. All of the above
23. Which of the following is correct regarding
tooth whitening for adolescent patients?
a. Careful screening is required
b. Patients under 15 should only be treated after careful
consideration
c. Professionally supervision is critical
d. All of the above
24. In-office whitening procedures typically
use H2O2 concentrations of:
a.20-30%
b.40-50%
c.25-35%
d.35-45%
25. Breaking down the carbon to carbon
double bonds in stain molecules:
a. Removes the stain
b. Lightens the stain
c. Has no effect on the stain
d. Darkens the stain
26. Setting patient expectations prior to tooth
whitening includes all of the following except:
a. Side effect development
b. Non-uniform initial results
c. Improved periodontal condition
d. Replacement of restorations
27. Soft tissue irritation from tooth whitening
may be caused by:
a. Ill-fitting trayss
b. Improperly applied barriers
c. Peroxide whitening agents
d. All of the above
28. Peroxide whitening agents work by:
a. Making single bonds into double bonds
b. Breaking double bonds into single bonds
c. Making double bonds into triple bonds
d. Breaking triple bonds into single bonds
29. Which of the following affects color
perception?
a. Absorption of light
b. Light reflection
c.Dentin
d. All of the above
30. Isolation during in-office whitening
include all of the following except:
a. Vinyl dam
b. Paint-on dam
c. Tofflemire band
d. Lip and cheek retractors
10www.ineedce.com
ANSWER SHEET
A Review of Tooth Whitening Services
Name:
Title:
Specialty:
Address:E-mail:
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City:
State:ZIP:Country:
Telephone: Home (
)
Office (
Lic. Renewal Date:
) AGD Member ID:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information
above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6)
Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
If not taking online, mail completed answer sheet to
Academy of Dental Therapeutics and Stomatology,
Educational Objectives
A Division of PennWell Corp.
1. Discuss the primary responsibilities of dental professionals.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
2. Describe the available tooth whitening agents and their mechanism of action.
3. Discuss the potential benefits and side effects of tooth whitening agents.
For IMMEDIATE results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
4. Describe the different types of tooth staining.
Course Evaluation
1. Were the individual course objectives met?
Objective #1: Yes No
Objective #2: Yes No
Objective #3: Yes No
Objective #4: Yes No
P ayment of $59.00 is enclosed.
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2. To what extent were the course objectives accomplished overall?
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11. Would you participate in a similar program on a different topic?
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Exp. Date: _____________________
Charges on your statement will show up as PennWell
12. If any of the continuing education questions were unclear or ambiguous, please list them.
________________________________________________________________
13. Was there any subject matter you found confusing? Please describe.
_________________________________________________________________
14. How long did it take you to complete this course?
_________________________________________________________________
15. What additional continuing dental education topics would you like to see?
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AGD Code xxx
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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included
with the course. Please e-mail all questions to: [email protected].
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done manually. Participants will
receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be
mailed within two weeks after taking an examination.
COURSE CREDITS/COST
All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE
credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/
Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact
their state dental boards for continuing education requirements. PennWell is a California Provider. The
California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.
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PROVIDER INFORMATION
PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association
to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours
by boards of dentistry.
Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada.
org/cotocerp/
The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General
Dentistry. The formal continuing dental education programs of this program provider are accepted by the
AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance
by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from
(11/1/2011) to (10/31/2015) Provider ID# 320452
RECORD KEEPING
PennWell maintains records of your successful completion of any exam for a minimum of six years. Please
contact our offices for a copy of your continuing education credits report. This report, which will list all
credits earned to date, will be generated and mailed to you within five business days of receipt.
Completing a single continuing education course does not provide enough information to give the
participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of
many educational courses and clinical experience that allows the participant to develop skills and expertise.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
IMAGE AUTHENTICITY
The images provided and included in this course have not been altered.
© 2015 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell
Customer Service 216.398.7822
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