Many of my patients ask for recommendations for at-home whitening modalities. How should I determine which is best based on individual patient characteristics?
Before considering any over-the-counter (OTC) products or starting any professional bleaching treatments, a thorough dental examination is indicated to assess for caries, existing restorations, white spots, discolorations, sensitivity issues and status of occlusion.1 Radiographs can assist in revealing reasons for dark teeth such as abscesses, calcific metamorphosis, caries, and internal or external resorption.2–4 The exam should include explanation of available treatment options and the expected results. Patients with existing restorations must be informed that the restorations will not bleach, so if they are visible in the smile, consideration will need to be made for possible replacement. Additional considerations include patient preference, treatment time, and financial commitment.
For professionally supervised at-home options, tray bleaching with 10% carbamide peroxide is well-researched, safe, effective, and efficacious. Trays can be fabricated in the dental office with traditional vacuum-formed materials or novel thermoplastic materials.5 A thermoplastic tray requires less chair time, lab work, and materials, thus, fabrication is less expensive. Instructing patients to bleach one arch at a time, starting with the maxillary arch can improve patient compliance as he or she can compare the progress over time. Charging a per-arch fee option offers less of an initial investment and allows the patient to decide whether to pursue treatment for the mandibular arch. Some offices may also offer disposable prefilled bleaching tray kits as an additional option. If the patient already has a tray that covers the teeth, then the office can merely supply the bleaching materials after the examination. Offices should be aware that, unfortunately, patients can purchase professional dental products from online retailers. As such, advise them to check the expiration dates before using. Remind patients they will not find the American Dental Association (ADA) Seal of Acceptance on any professional products since the ADA only approves consumer products.
If the patient would like to try an OTC bleaching product, whitening strips are less expensive than tray bleaching. Although the treatment time may take longer than the tray method, the results are comparable.6 Other OTC products, such as whitening toothpastes, do not change the internal color of the tooth. These products are useful to maintain the results once patients have bleached their teeth by continued removal of surface stains. Whitening toothpastes tend to be more abrasive than regular toothpaste so use caution when recommending to patients with aggressive brushing habits. Guide patients away from approaches such as the use of charcoal or oil pulling that are not evidence-based and may harm the enamel and gingiva.7,8
Several options are available for bleaching that can be tailored to the patient’s needs, expectations, and finances. Starting with a thorough dental exam and discussing the patient’s esthetic expectations will set you on the right path for a successful outcome.
- Haywood VB. Pre-bleaching exam vital for optimum whitening. Compend Contin Educ Dent. 2012;33:72–73.
- Haywood VB, Delash J. Determining appropriate fees for tooth bleaching. Inside Dentistry. 2019;15(6):34–41.
- Haywood VB, Bergeron BE. Bleaching and the diagnosis of internal resorption. Decisions in Dentistry. 2018:4(8):20–25.
- Haywood VB, Fortney LA. Diagnosis and prognosis for dark tooth bleaching. Decisions in Dentistry. 2019:19;5(3):10–14.
- Haywood VB, Delash J. Novel bleaching tray fabrication techniques. Inside Dentistry. 2021;17(1):31–36.
- Auschill TM, Hellwig E, Schmidate S, et al. Efficacy, side-effects, and patients’ acceptance of different bleaching techniques (OTC, inoffice, at-home). Operative Dent. 2005;30:155–163.
- Brooks JK, Bashirelahi N, Reynolds MA. Charcoal and charcoal-based dentifrices: a literature review. J Am Dent Assoc. 2017;148:661–670.
- Brooks JK, Bashirelahi N, Reynolds MA. More on charcoal and charcoal-based dentifrices. J Am Dent Assoc. 2017;148:785.
From Dimensions of Dental Hygiene. July 2022; 20(7)46.