May 28, 2019
by Susan Woodley, DH, RDH, Practice Consultant at dentalcorp
Many dental hygienists, including myself, say they entered this profession to assist clients in developing and maintaining healthy beautiful smiles. It is widely accepted that whitening gels play a significant role in developing those beautiful smiles. According to research from EKWA Marketing (2018) Trends in Teeth Whitening: $11 billion is spent yearly on products or procedures for whitening teeth; $0.9 billion is spent globally on teeth whitening strips every year; 89% of Orthodontists received teeth whitening requests; 99.7% of people believe that an attractive smile is an important social asset; and individuals are 58% more likely to get a job after whitening their teeth.1 These statistics are testament to the importance our clients place on a whiter smile.
The whitening conversation
Despite these statistics, dental professionals often find the whitening conversation uncomfortable. Perhaps they fear coming across like a sales person, or believe if the client doesn’t mention it, they must not be interested. In any case, we dental professionals are in the best position to have these whitening conversations with clients as we are equipped with the necessary evidenced-based information. Our clients are looking for our expertise to help guide their oral health decisions and teeth whitening should be no exception.
Having a Smile Evaluation form for all new clients to complete prior to their appointment can be a great conversation starter. This becomes the pathway to learn more about your clients’ wants, which can also translate into an important relationship building opportunity. When clients understand we care about their wants as well as their needs, a trust bond is formed. Additionally, having a Smile Evaluation form specific to recare appointments can be valuable in determining the wants for those we may not have had the opportunity to learn from. It also captures any changes, be it wants or needs, since their last visit.
Performing a baseline shade assessment is the next step in a comprehensive treatment plan. Ideally, involving the client in this process and having them identify their shade first, allows you a better understanding of how to proceed with your professional recommendations and provide realistic expectations for your client. Managing clients’ expectations is a vital component to the conversation. Not everyone’s teeth whiten at the same rate and, in some cases, teeth within the same mouth don’t whiten at the same time. Some individual teeth may require more time on task. The use of professional custom trays allows tailoring to those needs when or if this situation presents. The client can simply add whitening gel to the specific wells for teeth requiring more time.
Adjunctive Therapy to whitening
Dental professionals may be surprised to learn that research demonstrates the value of whitening gels in adjunctive therapy for caries risk and soft tissue management.
Hydrogen peroxide (HP) was first reported for intraoral use in 1913 to decrease plaque formation2 and has long been the treatment of choice for acute necrotising ulcerative gingivitis3 and pericoronitis.4 While initially identified for its therapeutic value, it was later discovered that it had a beneficial side effect of whitening teeth. Over time, whitening became the leader of
the story because it received more attention from our clients.
10% carbamide peroxide (CP) is the most thoroughly researched CP formulation and is widely preferred over HP for therapeutic use. Composed of 6.5% urea and 3.5% peroxide, 10% CP is active up to 10 hours in the mouth, while hydrogen peroxide is only active for 30 to 60 minutes.5 It further removes plaque, kills bacteria and elevates the mouth’s pH which results in fewer caries and acts as a tissue healing agent.
Careful consideration, however, should be taken before whitening gels are introduced in the presence of active caries. CP therapy is recommended for use in the prevention of carious lesions/white spot lesions as well as improving gingival health. Clients that can benefit from this adjunctive therapy include those with special needs where oral healthcare can present manual dexterity challenges; elderly clients; clients with xerostomia; clients undergoing orthodontic treatment; as well as clients who have demonstrated difficulty in maintaining an acceptable level of oral hygiene.
One method to consider for caries and soft tissue control is a customized, non-scalloped, no–reservoir tray, which extends 1 to 2 mm onto the gingival tissue. It should not extend into undercuts to the path of insertion, nor encroach on frenum attachments.6
Having an extensive background in Orthodontics myself revealed the challenges of home care efficacy and the far-reaching effects that can occur. Extensive white spot lesions and/or multiple carious lesions at the end of treatment too often result. Providing a therapeutic solution for both hard and soft tissue affords a practical option to deal with the problems of oral hygiene during orthodontic treatment. Invisalign trays can also be used for therapeutic healing (hard and soft tissue) as well as whitening teeth.
With traditional orthodontics, the use of thermoplastic trays works well. In this technique, the single clear soft tray is heated, softened in warm water that has been initially brought to a boil, then applied to the arch and directly contoured to the teeth by finger pressure. The patient then occludes into the softened tray and applies suction to form-fit the tray to the teeth. After the tray has cooled, the tray handle is then removed, and the tray trimmed to fit.8
A CP professional product that checks all the boxes is one that contains 10% CP, amorphous calcium phosphate and potassium nitrate (5% KN03) for sensitivity management. It protects hard tissue, helps heal soft tissue while managing sensitivity, provides lustre to the teeth and has the added bonus of a whiter smile.
As previously mentioned, the multipurpose of hydrogen peroxide extends to soft tissue healing. The known mechanism of antimicrobial action is the release of oxygen, and pathogenic effects that are seen in gram-positive as well as gram-negative organisms.10 Another mechanism of antimicrobial action is the effect hydrogen peroxide has on the debridement of bacterial cell walls. The presence of oxygen makes it difficult (if not impossible) for anaerobic bacteria to survive. Long-term bleaching studies involving recare visits have shown that CP application can be continued indefinitely to suppress plaque formation and control caries in patients who have difficulty maintaining acceptable levels of oral hygiene.11
An evidence-based solution
Knowing that research supports the use of professional whitening gels in adjunctive therapy for caries risk and soft tissue management, we can set aside faulty beliefs that a healthy mouth is necessary before teeth can be whitened. With that mindset, many of our clients would never be candidates for professional whitening and, as a result, prompt them to seek OTC methods or other online solutions lacking research to support their safety and efficacy.
As we have seen, whitening gels have tremendous potential to improve oral health with an added bonus of whiter teeth. Recommending evidence-based products like 10% carbamide peroxide can have a dual effect – both supporting your client’s whitening wants and needs and fulfilling your professional obligations. Perhaps your next whitening conversation just became a little easier!
2. Gold SI. Early origins of hydrogen peroxide used in oral hygiene. J Periodontal. 1983;54:247. [PubMed]
3. Farrell GW, McNichols WA. Efficacy of various medicaments in the treatment of Vincent’s Stomatitis. JAMA. 1937;108:630–3.
4. Mandel ID. Antimicrobial mouth rinses. J Am Dent Assoc. 1994;125:25–105. [PubMed]
5. Haywood (2007); https://www.dentaleconomics.com/articles/print/volume-100/ issue-1/features/bleaching-and-caries-control-in-the-elderly.html
6. (Haywood 2006, 2007); https://www.dentaleconomics.com/articles/print/volume-100/issue-1/features/bleaching-and-caries-control-in-the-elderly.html
8. http://www.vanhaywood.com/uploads/articlespage/2010%20Orthodontic%20 Caries%20Control%20and%20Bleaching.pdf
10. Marshall MV, Cancoro LP, Fischman SL. Hydrogen Peroxide. A Review of its uses in dentistry. J. Periodontol. 1995; 66:786-96.
About The Author
Susan Woodley is a Registered Dental Hygienist and Practice Consultant at dentalcorp. Throughout her career in dental hygiene, Susan has worked across general, orthodontic and pediatric practices. In her previous role as Manager of Professional Education for Philips Oral Healthcare North America, she provided continuing education courses to dental professionals as well as educational programs to dental, dental hygiene and dental assisting students across Western Canada. Susan is a published author and former part-time professor of dental hygiene and dental assisting programs. She and her husband now reside in Kelowna BC.
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