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techniques article
WHITER, BRIGHTER, HEALTHIER SMILES
FOR THE CHAIRSIDE ASSISTANT
A Whiter Smile
W
for Graduation Day
FREE 1
CEU COURSE
CREDIT!
By Shannon Pace Brinker, CDA CDD • CPS Magazine www.cpsmagazine.com
ith so many bleaching materials on the market today, it is really hard to determine which product to use and why. As dental assistants, we are not
trained to decide what is the best percentage of bleach; what is safest for a particular patient; and, most importantly, whether to use an in-office or
at-home treatment (or both). Most of the time we draw upon our own experience and our patients’ responses. In this article, we used several
different systems from Heraeus and SDI. We chose patients of varying ages and used differing methods for predictable results.
by Shannon Pace Brinker, CDA , CDD, Editor in Chief,
Contemporary
HOW DOES WHITENING
WORK?Product Solutions • www.cpsmagazine.com
The peroxide in the whitening solution breaks down into water and oxygen ions. The oxygen ions enter the enamel and dentin and are attracted to the staining
molecules. The oxygen ions attack and destroy the double bonds, leaving shorter stain molecules. Double bonds create discoloration and, once broken, the
discoloration and the compounds are removed.
WHAT ARE THE DIFFERENCES BETWEEN HYDROGEN AND CARBAMIDE PEROXIDE WHITENING?
Hydrogen is used for most in-office procedures and can cause more sensitivity. Hydrogen is usually activated by light and is stronger and faster than carbamide
peroxide. It is easier for the patient because the dental team does all the work. Carbamide peroxide is recommended for whitening tray wear and can be used day
or night. Carbamide causes less sensitivity and has more effect on dark stains but must be worn longer for more effective results.
COMPREHENSIVE ORAL EXAM AND RECORDS
The dentist must first make an assessment as to whether the patient is an ideal candidate for bleaching. We suggest that the patient first undergo a thorough
dental hygiene visit to remove extrinsic stain, calculus, and plaque. During this initial visit, we can provide dental X-rays, periodontal charting, digital
photography, and pre-operative study models for home-trays if needed. Make sure to take pre-operative photos with and without a shade guide to prove
Shannon
Pace Brinker,
shade
change.
CDA a National and
International Speaker
and published
author.
WHO
IS A CANDIDATE?
Shannon,
Editor
in Chief,
Teeth
that are
yellowish-brown
(a shade range) and typically stained from aging tend to whiten more rapidly than teeth that range from gray to grayish-brown
her husband
Erik,Mktg
own to check this. Patients who consume large quantities of dark soft drinks, tea, coffee, grape juice, red wine, and/or use tobacco will
(Cand
to D)????
Mike…ask
Contemporary
Product
achieve greater success with the in-office procedure as compared with an at-home bleaching procedure. White stains do not go away and may even get lighter
Solutions,
which provides
during
the whitening
process. Teeth with tetracycline stains, decalcifications, traumatic injuries, or root canal therapy may require additional visits and possible
product
the
home
tray reviews
alliancefor
to achieve
optimal results. Please note that bleaching is not recommended for women who are pregnant or breast-feeding.
complete dental team. It is
the only dental editorial that
combines
product
WHAT
ARE
THE review
MAINforCAUSES OF SENSITIVITY?
the of
whole
team.sensitivity is caused from recession, abrasion, erosion, and dehydration. During the first 24 hours of treatment after in-office whitening some
Most
the time,
patients
mayPace
experience
Shannon
Brinker, some tooth sensitivity or pain. Normally that goes away after 24 hours, but in rare cases can persist for longer periods of time. Most
offices
CDAwill
is arecommend
past faculty sodium fluoride (Remin Pro Voco) (MI Paste GC America) be placed in the tray for 30 minutes before or after the whitening process.
member at the Dawson
Among the first characteristics people notice in treated teeth.9 Key to establishing whether or not
Academy and Spear
PRODUCT
TYPES
others is the shade of their teeth and the whiteness a patient with such teeth is a candidate for internal
Education. She
is an
1,2
There
aremember
three basic
types of whiteningofprocedures
our office
offers; they
are:
active
of the
their smile.
Visible
differences
in the shade tooth whitening is examining the vitality of the
AACD. Shannon
is whitening)
the
• In-Office
(one-hour
with take-home
trays teeth detracts from their overall pulp, presence and absence of symptoms, and presof someone’s
first auxiliary
to sit on
thewhitening) Day or Evening1,2wear
• Take-Home
(custom
tray
appearance. Not surprisingly, tooth whitening ence or absence of periapical pathoses. Regardless
AACD Board of Directors.
• Pre-Filled
(disposable
trays)products and procedures are among the most of patient age or the specific tooth being treated,
Shannon was
selected whitening
one
of Dentistry Today’s Top
commonly performed esthetic restorative treatments whitening endodontically treated teeth has been
100 Clinicians of 2009,
in modernTRAYS
dentistry.3,4 Now available in a variety of shown to be predictable.10
PRE-FILLED,
DISPOSABLE
WHITENING
2010, 2011 and 2013.
product
types,
there
are teeth
whitening
treatments hydrogen
The
Venus
Ultra by
is pre-filled
with
an 11.2% mint-flavored
peroxide
gel that is are
wornamong
for one hour
day for
up
She
was White
also selected
as Heraeus is a disposable tray that
Whitening
treatments
the aleast
invato Dental
seven days.
EachReport
set comes
andever-changing
lower tray that self-adheres
to the tooth arches with just a pinch. This pre-filled tray is for teenagers and young
to meet
patient needs.
Products
25 with an upper
sive
and
most
cost-effective
procedures
available
to
adults
are looking
forina lighter, brighter smile.
mostwho
influential
women
There are over-the-counter options with low con- enhance a patient’s smile.11 However, dental team
dentistry and Dr. Bicuspid’s
centrations of peroxide-based agents in trays and members must still take care when selecting a whitDental Assistant Educator
of the year for 2012. She
strips; in-office gels ening agent, since some products may be harsh and
is the Editor in Chief for
with high concentra- increase the likelihood of soft-tissue irritation and
1
Contemporary Product
tions of hydrogen per- burns.12 Additionally, some products may cause sigSolutions and consultant for
oxide; and specialized nificant treatment and post-treatment sensitivity.13
many dental manufacturers.
For information on dental
lights to enhance whit- Although this sensitivity may decrease as treatment
assistant programs, please
ening effectiveness.5,6 continues, it can still result in patient discomfort.13
contact her at 757-285-9477
Recent offerings in- Therefore, dental team members should choose a
or email at
clude additives such product that is both well tolerated and effective.
[email protected].
Figure 1–Dry teeth with as
a cloth
or paper
Figure 2–Mold the Venus White Ultra
potassium
nitrate
towel before placement and
of the Venus
fluoride to pre-filled
reduce strip to the arch form
White Ultra. Remove from packaging 7,8
of the upper arch.
sensitivity.
and place strip on upper teeth.
Figure 3–Mold the Venus White Ultra
pre-filled strip to the arch form
of the lower arch.
Ensuring Successful Whitening
Venus White Ultra 11.2%.
Additionally,whitening
techniques now make it
possible to esthetically
enhance traumatized
and/or endodontically
2012 SELECT
18
Fax Your Order:
A proper consultation and examination are essential
to determine whether or not a patient is a candidate for whitening treatment. Patients with tooth
discolorations caused by age, food or drink, medications, fluorosis, or endodontic treatment are typi-
1.800.732.7023 24 Hours
3
4
Figure 1. Pre Op before
whitening.
Figure 2. Pre Op smile.
Figure 4–Retracted view of the Venus
White Ultra in place on the maxillary
and mandibular arches.
Figure 3. Pre Operative
Smile with
shade tab.
Figure 5–Patient is instructed to wear for
1 hour per day for 7 days. Patient is then
instructed to return for a follow-up visit
and shade check with photos.
Figures 6 and 7–Before and after, using the Venus White Ultra for 7 days.
Figure 4. Opened endo
acess lingual #9.
like the overall color of his smile. Minimal
cally the best candidates.14-16 However, prior Whitening Protocol
intervention and biomimetic approaches
restorative work, such as veneers or crowns,
FABRICATION
FOR WHITENING
TRAYS
will only demonstrate
a whitened
effect to Regardless of the specific whitening treat- ultimately are where our beliefs are with the
There are several materials to choose from when it comes toment
the whitening
In my practice
we use both polyvinyl and alginate. What is very
or whichfor
team
member trays.
performs
the patient.
We know in the future this tooth will
the underlying
tooth structure and around the impressions
important is the14-16
detail that is captured in that impression. The whitening tray must seat and fit properly. Over the years, I have been asked to I block out my model
procedure,
the
dentist
should
always
evaluate
need
a restoration,
but
we400
feel
doing the least
margins.
Patients
with
discolored
restorawhen fabricating a whitening tray. Is it necessary to cut the papilla to minimize tissue irritation? From my own experience
in performing
over
whitening
patient’s
oral health
beforehas
anybeen
whitening
amount
of dentistry
accomplish
his
wishes
tions should
consider
having
them
procedures
within the
last 2 years,
it has
madereplaced.
no differencethe
whether
the block
out or papilla
removed from
the tray.
The choiceto
is really
up to the
patient.
treatment.
In everywith
whitening
case,
proper
We offer several types of whitening in our practice. When discussing
compliance
the patient,
it isavery
important
tothe
help
the patient
to understand that this is
was
most
important.
Additionally,
aretheir
pregnant
an investment
and wepatients
do not wantwho
to waste
time if theyseries
are not
to follow-up.
our practiceshould
we have nighttime wear and daytime wear. We allow the
ofgoing
photographs
andIn
radiographs
The
protocols
helpWetoalsoensure
or tolactating,
havemakes
untreated
caries or Poladay
have be
patient
choose, which
them accountable.
by SDI
home-tray
whitening
gives the
patient
the option
of afollowing
30-minute whitening
at 9.5%.
offer
taken,
detailed
impressions
made
(except
the patient
that isimproper
an overnight
wearhygiene,
carbamide peroxide gel at 10%. Teeth-whitening gel will only whiten
natural teeth.
optimum
outcomes
for
in-office
internal
excessa polanight
plaque from
oral
with pre-filled), and the fit of the bleaching
whitening and custom tray whitening
and those allergic to whitening ingredients trays should be checked.
treatments.
should not undergo whitening treatments. In
these cases, patients must wait until they are The Venus White Max 38% Hydrogen Per- Pre Operative Photos of patient’s full face and
(Heraeus, South Bend, IN) in-office
no longer pregnant, or until their cariesAnother
and oxidephoto
retracted smile with shade tab (Figure 1- 3)
plaque issues have resolved. Patients who use treatment allows patients to see immediate
for
this?
results
similar
to
those
achieved
when
whitPlace a retractor Discus Dental and a bite
tobacco products on a regular basis, with no
plans to stop, may benefit from whitening ening for a week with tray-based systems. block with a tongue retractor to prevent
treatment but will need to continue regular The Venus White System is simple to use, the patient’s tongue from contacting the
highly effective and can be used by any den- whitening agent.
whitening to maintain their results.
Figure 1–Make sure
are clean
and
Figure 2–Remove
syringewhitfrom case and load
taltrays
team
member
trained
to provide
your teeth and gently press
The endo Position
access tray
wasover
opened
with a carbide
Once a patient is determineddrytopriorbeto applying
a ening
SDI Poladay
9.5%
the tray with SDI Poladay
9.5%, depress the
tray to move the gel into place. Do not press too
to patients.
Additionally,
the Venus
burwith
toaremove
the old
composite
candidate for whitening, the type of White System represents
plunger, and fill each tooth in the tray
hard—only
enough
to
seat
on restoration.
teeth. Wear tray
advancements in
of gel. One syringe will be used
for two 4)for 30 minutes a day from 10 to 14 days. Remove
(Figure
treatment (e.g., in-office, take-home, or material sciences andpearl
whitening,
days
of whiteningwith
or twoprodapplications of top
trays after 30 minutes. Brush teeth and inside of
pre-filled)
Whiter
Brighter Youmost appropriate for the patient ucts containing potassium
the twotraysVenus
Max
nitrate to practi- Connect whitening
and bottom.
to removeWhite
access material.
both financially and esthetically is selected. cally eliminate sensitivity.7,8,19
syringes and mix by clicking back and forth
Additionally, a series of clinical photographs
approximately 25 times (Figure 5). Place
should be taken, including a full-face, smile, Although predictable and satisfying results the tip on the syringe.
and retracted smile with shade tab to allow can be achieved in one in-office treatment,
the patient to observe their results once patients should still first have the necessary Apply an expanding liquid gingival barrier
photographs taken and impressions made. to the patient’s soft tissues on the facial and
treatment is complete.
This is necessary because ideal results are lingual and light-cure (Figure 6). Check the
The effectiveness of any whitening treatment achieved by following in-office whitening barrier with an air/water syringe to ensure
is wholly dependent on the percentage of with two weeks of bleaching using the take- no areas remain exposed.
bleaching agent (i.e., hydrogen peroxide home Venus White Pro and custom trays.
Dispense the Venus White Max into the
or carbamide peroxide) in the solution and
Figures 3 and 4–Before and after full face.
endo access opening and onto the facials of
the amount of time the teeth are exposed
5,17,18
the teeth (Figure 7). Since the gel is viscous,
to it.
The fit of the trays, regardless of Case Presentation
it adheres strongly to the teeth, so there is
whether custom trays are used as the primary
or secondary treatment option, is of the An 18-year-old male was dissatisfied with the no need to agitate.
utmost importance for a successful whitening appearance of the anterior maxillary tooth After 10 minutes, remove the whitening gel
treatment because they keep the whitening No. 9. The tooth was endodontically treated with suction. Repeat steps 6 and 7 a total of
twoears prior after a baseball accident. The
agent in contact with the teeth.5,17,17
three times.
patient was graduating soon and really didn’t
Figure 5. Connect the two
VenusWhite Max
syringes and mix by
clicking back and forth
for a total of 10 times.
Figure 6. Gingival Barrier
placedon the ligual
and Venus White Max
placed inside of tooth.
Figure 7. Venus White Max
placed on facial of
anteriors.
5
6
techniques article
2
7
Figures 5 and 6–Pre Op Shade A1 to a BL4.
To Order, Call Us Toll-Free:
1.800.372.4346 8am–9pm, et
19
techniques article
8
IN-OFFICE
WHITENING
eymann HO. Facts and fallacies. BR Dent J.
If the patient experiences sensitivity during 5. H
2005;198(8):514.
the teeth.
procedure
or presents
priorwhitening
sensitivity
In-office bleaching provides the quickest way to whiten
Venus White
Max is with
an in-office
treatment
that consist of a 38% hydrogen peroxide gel that is
applied for 2 (30) minute sessions without the use ofissues,
a light. The
patient
is instructed
afterin-between
the in-office whitening
follow
the treatment with 2tooth-whitening
weeks of take-home
apply
fluoride
varnish
the 6. K
tougel
G.upOver-the-counter
whitening (One hour a day for 14 days or the patient15-minute
may choose to
have another
whitening
intervals;
thisin-office
will not
affectprocedure.).
the
systems. Compend Contin
2003;24(4A):376-82.
whitening outcome.
Educ
Dent.
After the in-office treatment is completed, 7. Tam L. Effect of potassium nitrate and fluoride
patient was given his custom trays with
on carbamide peroxide bleaching. Quintessence
Venus White Pro gel 22% and instructions
Int. 2001;32(10):766-70.
for whitening for one hour once a day for two 8.Leonard RH Jr, Smith LR, Garland GE,
weeks. The patient returned for a 2nd visit to
Caplan DJ. Desensitizing agent efficacy during
repeat the same steps.
whitening in an at-risk population. J Esthet
Dent. 2004;16(1):49-55; discussion 56.
Final shade check after 2 in-office treatments
and 14 days of take home tray whitening patient 9. Kwon SR.Whitening the single discolored
is now BL 3 on the Chromoscope Bleach Guide
tooth. Dent Clin North Am. 2011 Apr;55(2):229by Ivoclar Vivadent (Figure 8).
39, vii.
9
Figure 2–Pre Op Shade Tab D3
Final full face and retracted smile photo after 10.Patient’s
teeth
been pumiced.
Retractorbleaching
and
A
bbott
P,have
Heah
SY. Internal
of
gingival
have beenof
placed.
treatment. (Figure 9 and 10)
teeth:barrier
an analysis
255 teeth. Aust Dent J.
2009 Dec;54(4):326-33.
The patient sent me a final graduation photo of
11.
Burrows S. A review of the safety of tooth
his proudFigure
new 1–Full
smileFace
(Figure
11)
Pre-Operative
Venus White Max
10
bleaching. Dent Update. 2009;36(10):604-6,
608-10, 612-4.
Photo with Shade tab.
Conclusion
12. G
oldberg M, Grootveld M, Lynch E.
Undesirable and adverse effects of tooth
The greatest benefit of the Venus White
whitening products: a review. Clin Oral Investig.
System is its ability to truly make a difference in
2010;14(1):1-10. Epub 2010 Jun 20.
patients’ lives. Minimally invasive, cost-effective,
and efficient, the Venus White System provides 13. J orgensen MG, Carroll WB. Incidence of tooth
patients with the ability to improve their smiles,
sensitivity after home whitening treatment. J
regardless of age or economic status. To fully
Am Dent Assoc. 2002;133(9):174.
implement tooth whitening, the practice must
14. S
ulieman M.An overview of tooth discoloration:
take a team-based approach and train all staff
extrinsic, intrinsic and internalized stains. Dent
on the procedures and protocols required for
Update. 2005;32(8):463-4, 466-8, 471.
effectiveness and safety.20 With these systems
11
15.
V
iscio D, Gaffar A, Fakhry-Smith S, Xi T.
in place, and when the best in material science
Present
and future technologies of tooth
is utilized,
whitening can truly provide patients Figure 5–Suction
Figure 3–Mix the Venus White Pro 38% hydrogen
Figure 4– After 30 minutes, suction off whitening
Venus White Max
and rinse.
whitening. off Compend
Educ
Dent Suppl.
with
life-changing
results.
peroxide gel. Apply 1 mm of Venus White Max gel
agent and reapply for another 30-minute session.
Remove the gingival barrier and retractor. Take a
2000;(28):S36-43; quiz S49.
to facials of teeth for 30 minutes.
final photo and instruct patient on the use of the
take-home
16.
H
attabtrays.
FN, Qudeimat MA, al-Rimawi
HS.
Dental discoloration: an overview. J Esthet
Dent. 1999;11(6):291-310.
References
Figure 8. Final shade after whitening.
Figure 9. F
inal retracted smile after
whitening.
Figure 10. F inal smile after 2 in-office
treatments and 3 weeks of
take home treatments with
take homewhitening trays
and 22% Venus White Pro.
Figure 11. Patient’s Graduation photo.
17. H
aywood VB, Heymann HO. Nightguard vital
bleaching. Quintessence Int. 1989;20(3):1731. Samorodnitzky-Naveh GR, Geiger SB, Levin
176.
L. Patients’ satisfaction with dental esthetics. J
AM RESOURCES:
Dent Assoc. 2007;138(6):805-8.
18. Haywood VB. Historical development of
whiteners: clinical safety and efficacy. Dent
References
2. Dunn
WJ, Murchison DF, Broome JC. Esthetics:
Update.
1997;24(3):98-104.
1. Haywood
VB. Tooth
Indications and
of Nightguard
Vital Bleaching. Hanover Park,
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of Whitening:
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J outcomes
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Publishing Company Inc; 2007.
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19. Venus White Teeth Whitening System.
2. Matis BA. Tray whitening: what the evidence shows. Compend Contin Educ Dent. 2003; 24(4A):354–362.
(2010). Show the world your most beautiful
3. Swift EJ. Critical appraisal: effects of bleaching
3. Gottardi MS, Brackett MG, Haywood VB. Number of in-office light-activated bleaching treatments
smile. [Brochure]. Heraeus, South Bend, IN.
on needed
tooth tostructure
and
restorations,
part
achieve patient satisfaction. Quintessence Int. 2006;37(2): 115–120.
ii: enamel
bonding.
J
Esthet
Restor
Dent.
20. Dof
uello
GV. The
utilization
of an
4. Browning WD, Swift EJ. Critical appraisal: comparison
the effectiveness
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of carbamide
2008;20(1):68-73.
peroxide whitening agents at different concentrations. interdisciplinary team approach in esthetic,
J Esthet Restor Dent. 2007;19(5):289–296.
implant, and restorative dentistry. Gen Dent.
4. Sarrett
DC. Tooth whitening today. J Am Dent
Cooper JS, Bokmeyer TJ, Bowles
WH. Penetration of the
pulp chamber by carbamide peroxide bleaching
2004;52(2):116-9.
Assoc.5. 2002;133(11):1535-8;
quiz 1541.
agents. J Endod. 1992; 18:315–317.6. McCaslin AJ, Haywood VB, Potter BJ, et al. Assessing dentin color
changes from nightguard vital bleaching. J Am Dent Assoc. 1999;130:1485–1490.
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Figure 7
Final Fill Face Photo
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CE CREDIT
8. Haywood VB. Treating sensitivity during tooth whitening. Compend Contin Educ Dent. 2006;26(9):11–20.
9. Leonard RH, Haywood VB, Phillips C. Risk factors for developing tooth sensitivity and gingival irritation
associated with nightguard vital bleaching. Quintessence Int. 1997;28: 527–534.
All participants scoring at least 80% on the examination will receive a certificate verifying
10. McKamie
Deep bleaching:
one practice’s
for enhanced
patient satisfaction.
1 CEU Credit. To take the test
andA.receive
credit,
or protocol
request
a sample
please go to
Contemporary Esthetics. 2007;10:12–19.
http://cpsmagazine.com/one-ce-credit-graduation-day
20
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1.800.732.7023 24 Hours