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Eliminating Tooth Sensitivity During Tooth Whitening A Five Case Study

August 1, 2015
by Ron Goodlin, DDS, AAACD, FIADE, FAGD


The advent of specialized chemistry in the “Zoom Whitespeed” (Fig. 1) (Philips) tooth whitening system has all but eliminated the concern over tooth sensitivity during bleaching procedures.1,2 There do remain, however, some patients, who have experienced severe sensitivity when they had attempted bleaching procedures in the past. These patients require extra consideration before attempting bleaching procedures again in order to alleviate those concerns over potential tooth sensitivity.

FIGURE 1. Zoom whitespeed with variable intensity light.

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The Clinical study and Patient Demographic.
Only younger patients, those who have complained of tooth sensitivity previously, or patients who have not been able to complete tooth whitening procedures in the past were chosen for this study.

Patient 1:
Lisa M, 40 years old, presented to the office expressing an interest in whitening her smile but expressing concerns over her being unable to complete treatment when she tried bleaching about five years ago. She also tried an over the counter self-application tooth whitening technique which also created an exaggerated sensitivity that has caused her to become quite concerned about the bleaching procedure.

Patient 2:
Charlotte A is 16 years old with yellow teeth, and she felt whitening would enhance her smile and her confidence. She has not tried whitening before however her teeth are generally sensitive to cold and she has some difficulty when eating ice cream.

Patient 3:
Yvonne V is 24 years old. She has had sensitive teeth to cold and has tried whitening with over the counter products but did not continue due to tooth sensitivity during and following application.

Patient 4:
Natasha D is 15 years old and is a part time model. Her hope is to move from runway modelling to studio and advertising, and possibly TV commercials. She feels the enhancement will be important to her career. Her teeth are generally sensitive to cold. She has tried whitening toothpastes.

Patient 5:
Tess P is 20 years old and has tried tooth whitening before but had to stop mid procedure do to tooth sensitivity. She reports her teeth are generally sensitive to cold.

Studies have indicated that tooth sensitivity is related to stimulation of nerve tissue through the hydraulic action of the fluid inside the dentinal tubules. 3

Clinical Protocol
Patients were examined and interviewed to ensure they fell into the category of age and history of tooth sensitivity. Clinical exam for all of these patients revealed mild to moderate yellowing of the teeth with some minor surface staining.

Patient 4 Natasha D had an existing composite buildup on tooth 11 with staining, and was scheduled to have crown lengthening surgery and veneers placed after the tooth whitening procedure. (Fig. 2)

FIGURE 2. Patient ND before treatment.

Otherwise there was no evidence of decay, leaking restorations or gingival recession which would all be potential causes for tooth sensitivity during the bleaching technique.

Shades were taken using an OTT light (Fig. 3) (OTT Light corp. Florida USA) to simulate daylight, utilizing the Vitapan (Vita corp) shade tab system along with bleaching shades arranged according to value. (Fig. 4) Each shade was given a number to assist in determining the number of shades of improvement achieved from the tooth whitening regimen. (See table 1) Although these were subjective determinations, a consensus of opinion was taken with the Dentist an Assistant and a Hygienist in the clinical operatory.

FIGURE 3.  Shade taking with OTT light.

FIGURE 4. Vitra shade tab.

 

After discussion with each patient, informed consent was obtained to proceed with the following regimen consisting of 3 distinct phases. Each patient then signed a photo release.

First, each patient agreed to a pre-operative desensitization phase using “Fluoridex” (Philips) toothpaste for 4 days. (Fig. 5)

FIGURE 5. Fluoridex high fluioride concentration desensitizing toothpaste.

The second phase consisted of the “Zoom Whitespeed” in office bleaching procedure utilizing their variable intensity light activation system. (Fig. 6)

FIGURE 6. Zoom Whitespeed.

The third and final phase was a whitening boost utilizing a custom made tray with “Night White” (Philips) for 3 days, 1 hour each night following the in office procedure. “ACP Relief Gel” (Philips) was to be applied post operatively in order to alleviate any post-operative sensitivity. 4

Pre Treatment
Each patient was instructed to use Fluoridex toothpaste twice daily for a minimum of 4 days prior to the tooth bleaching appointment. Fluoridex toothpaste contains 1.1% Neutral Sodium Fluoride and 5% Potassium Nitrate designed to plug dentinal tubules as well as chemically relieve sensitivity. Studies show that toothpastes with 5000 ppm fluoride provide demonstrable benefits for the high-risk patients
. 5,6

In office procedure
The patients reported complying with the proposed regimen and attended the office for their bleaching appointment. In each case, an alginate impression was taken and a custom tray was fabricated (Fig. 7) to be used after the bleaching procedure, for use with an at home bleaching product, (Fig. 8) Philips Zoom Nite White (in order to boost the whitening in future) as well as for the application of the ACP relief gel. The soft plastic tray was custom made while the patient was undergoing the in office Zoom whitening procedure so it was ready for the patient when they completed their in office whitening appointment. Clinical photographs were taken before treatment using a standardized technique.7 (Fig. 9a-c)

FIGURE 7. Fabrication of custom tray using soft acyrlic sheet.

FIGURE 8. Custom trays for application of Nite White and Relief ACP gel.


FIGURE 9A.
Before Facial view 110 magnification ratio, f4 @ 125 sec using ring flash.

FIGURE 9B. Before Smile view 12 magnification ratio, f16 @ 125 sec using ring flash.

FIGURE 9C. Before rewtracted view 12 magnification ratio, f16 @ 125 sec using ring flash.

The teeth were then prophied using a wet slurry of chlorhexidine and pumice, a “before shade” (see table 1) and clinical photographs were taken. Teeth were dried and the tooth isolation protocol (Philips Zoom Whitespeed) using gauze, cotton roll isolation, a special retractor and Liquidam (Discus) a low viscosity flowable light cure resin material7,8 was applied. (Fig. 10) Zoom Whitespeed gel was applied to the teeth and the zoom light was positioned, and activated on the “high” (high medium and low settings are available) setting. (Fig. 11)

TABLE 1. Vitapan shade tab with shades arranged according to value.

FIGURE 10. Isolation technique with liquid dam.

FIGURE 11. Zoom Whitespeed application using variable intesnsity light activation.

 

The patients were constantly monitored and were instructed to tell the dental assistant if there was any sensitivity. In each case following each 15 minute session the patients reported zero sensitivity. The Zoom whitespeed gel was rinsed off, fresh gel reapplied and the procedure was repeated completing a total of three 15 minute sessions in each case, with zero reported sensitivity. Post—oerative photos were taken and the patient shade was noted utilizing the Ott light and consensus technique. (See table 2)

TABLE 2.

Following the Zoom Whitespeed procedure a fluoride treatment using “Neutra-foam” 2.0% sodium fluoride (Oral B) (Fig. 12) was provided in a Styrofoam tray for 2 minutes, Finally, “ACP relief gel” (Philips) (Amorphous Calcium Phosphate, fluoride and potassium nitrate) was applied using the custom tray for 15 minutes, as a preventive measure. ACP gel has been shown to allow enamel remineralization as the Fluoride is absorbed into the hydroxyapetite crystalline structure and then attracts calcium ions, followed by phosphate ions, leading to enamel re-mineralization.9

FIGURE 12. Neutra Foam fluoride

Post op protocol
The patients were dismissed with post op instructions regarding the exact protocol for the third phase — the “nitewhite” whitening boost and the use of the ACP relief gel. The patients were instructed to maintain a “clear” diet until 48 hours fo
llowing the final nite white application. Each patient was given a form in which to write down if there was any reported sensitivity, and if so to rate that sensitivity out of 10, Zero indicating no sensitivity, 10 being excruciating pain”

The whitening boost at home regimen included the custom tray and 1 syringe of Philips “nitewhite” (Fig. 13) used for one hour each day for the following three days (beginning the day following the in office procedure) Patients were shown how much to drop into the well of each tooth to be boosted. Patients were instructed to rinse the tray and apply the Relief ACP gel to the tray and wear it for 15 minutes after completing the 1 hour of the “nite white” application.

FIGURE 13. Nitewhite (philips) at home whitening gel.

FIGURE 14-1. Patient 1: before face LM

FIGURE 14-2. Patient 1: Smile before.

FIGURE 14-3. Patient 1: Retracted before.

FIGURE 14-4. Patient 1: Face after.

FIGURE 14-5. Patient 1: Smile after.

FIGURE 14-6.  Patient 1: Retracted after.

FIGURE 15-1. Patient 2: Face before.

FIGURE 15-2. Patient 2: Smile before.

FIGURE 15-3. Patient 2: Retracted before.

FIGURE 15-4. Patient 2: Face after.

FIGURE 15-5. Patient 2: Smile after.

FIGURE 15-6. Patient 2: Retracted after.

FIGURE 16-1. Patient 3: Face before.

FIGURE 16-2. Patient 3: Smile before.

 

FIGURE 16-3. Patient 3: Retracted before.

FIGURE 16-4. Patient 3: Face after.

FIGURE 16-5. Patient 3: Smile after.

FIGURE 16-6. Patient 3: Retracted after.

FIGURE 17-1. Patient 4: Face before.

FIGURE 17-2. Patient 4: Smile before.

FIGURE 17-3. Patient 4: Retracted before.

FIGURE 17-4. Patient 4: Face after zoom.

FIGURE 17-5. Patient 4: Smile after zoom.

FIGURE 17-6. Patient 4: Retracted after zoom.

FIGURE 17-7. Patient 4: Face after treatment.

FIGURE 17-8. Patient 4: Smile after treatment.

FIGURE 17-9. Patient 4: Retracted after treatment.

 

FIGURE 18-1. Patient 5: Face before.

FIGURE 18-2. Patient 5: Smile before.

FIGURE 18-3. Patient 5: Retracted before.

FIGURE 18-4. P
atient 5: Face after.

FIGURE 18-5. Patient 5: Smile after.

FIGURE 18-6. Patient 5: Retracted after.

Results
Each patient returned 4 days later for a follow up appointment, collection of data, discussion, final shade selection and photographs. In each case the patients reported complying with the protocol as described above. The patients returned to the office after 3 days for a post op photos and final shade and report on sensitivity. (See table 2)

Conclusion
This case study demonstrates that, younger patients, and those who have demonstrated a high degree of tooth sensitivity, are able to receive tooth bleaching procedures without the concern of discomfort. The “Zoom Whitespeed” system in conjunction with the adjustable light intensity and the regimen of a pre- treatment application of “Fluoridex” toothpaste and the post-operative application of “ACP relief gel” has been shown to be clinically effective in eliminating tooth sensitivity during and following tooth bleaching.OH


Dr. Goodlin is the immediate past president of the American Academy of Cosmetic Dentistry. He practices in Aurora, Ontario. Dr. Goodlin is happy to answer questions and can be reached at ron@smiledental.ca.

Oral Health welcomes this original article.

References:

1. Giniger M1, MacDonald J2, Ziemba S2, Felix H2, The Clinical Performance of Professionally Dispensed Bleaching Gel With Added Amorphous Calcium Phosphate, JADA, 136, 2005.

2. Osuna, T, The sensitivity complaint, RDH 03/01 2015 Vol 35 issue 3

3. Miglani, S Aggarwal V Ahuja B Dentin hypersensitivity: Recent trends in management J Conserv Dent 2010 Oct Dec 13(4) 218-224

4. Tung M, Eichmiller F. Amorphous Calcium Phosphates for Tooth Mineralization. Compendium 2004 Vol 25, No.9 (Suppl 1)

5. Schiff T, et. Al. Efficacy of a Dentifrice Containing Potassium Nitrate, Soluable Prophosphate, PVM/MA Copolymer and Sodium Fluoride on Dentinal Hypersensitivity: A twelve week clinical study. J Clin Dent (sp issue); 87-92, 1994.

6. Schiff T, Saletta L, Baker RA, Winston JL, He T. Desensitizing Effect of a Stabilized Stannous Fluoride/Sodium Hexametaphosphate Dentifrice Compend Contin Educ Dent. 2005;26 (Suppl1):35-40

7. Bassett, J Kurtzman G, Simplified chairside whitening, Dent Today feb 2011 19:11

8. Lineberry J, Using a ‘Liquid Dam’ in Your Restorative Practice Spear Digest March 2014

9. Li Y, Lu H, Zhang W, Hou J, Devaraj A. Effect of Relief ACP on Dentin Microhardness and Surface Morphology. J Dent Res 86 (Spec Iss A), 1776, 2007.


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