Aesthetic Dentistry Article: Tooth Whitening Step by Step Guide
Kiran Shankla examines a recent tooth whitening case with guidance on patient engagement, examination insights, and optimal treatment plans for long-lasting and effective results.
FIGURE 1: Preoperative
A 33-year-old female attended for a routine examination. Before carrying out an intraoral examination, the patient was asked if she had any dental concerns and if she was happy with the appearance and colour of her teeth (Figure 1).
Often, a patient attends a routine examination, sits in the chair, and leaves without being asked how they feel about their teeth. Asking these leading questions can help prompt a practitioner to discuss available treatment options depending on the patient’s response.
In this case, the patient reported she did not like the colour of her teeth but was happy with her smile and the position of the teeth. This automatically led to a natural conversation regarding tooth whitening and if the patient had ever considered this.
It is vital at this stage to set the patient’s expectations regarding whitening. Patients must be informed that if they are looking for a fake, white, bleach-coloured smile, the whitening alone will not produce this.
They must also be informed that everyone’s teeth will respond differently; there is no guarantee how long it will take for the teeth to appear whiter, and treatment can vary between two to four weeks. Sometimes, it may take even longer, which will incur further costs.
Examination/test results
An intraoral examination should then take place. When carrying out an intraoral exam for whitening, the following areas should be assessed:
- Current shade – a preop shade using a Vita guide should be taken and confirmed in a mirror with the patient. This should be followed up with a high-resolution photograph with a shade tab held near the canine, which should then be uploaded to the patient records
- Oral hygiene – this must be optimum before starting whitening to get the best results and dental prophylaxis should be undertaken first before any impression-taking
- Dark teeth – if any teeth are darker than the surrounding teeth, a periapical radiograph should be taken to establish the cause, eg post-RCT treatment/calcific metamorphosis Recession defects – patients should be informed that these areas will not change colour
- Signs of bruxism – these patients are much more likely to suffer from sensitivity during whitening, so they must be pre-warned
- Any current sensitivity issues – these patients are more likely to suffer from sensitivity during treatment; therefore, they may need to place a desensitising agent that contains potassium nitrate in the trays for an hour prior to bleaching or only carry out bleaching on alternative nights.
Treatment planning
Treatment options in this case included:
- No treatment
- A round of in-surgery whitening
- At-home whitening
- At-home plus in-surgery whitening.
A decision was made to whiten the teeth at home. The patient had a 3D digital scan taken, which was sent to a local lab to produce a set of whitening trays. The design of the trays must be specified; if the trays are too thin, they will flex more and cause more sensitivity issues. Generally, a 0.035” soft, flexible, vacuum-formed, non-reservoir tray should be requested.
The patient was provided with an at-home kit of SDI Pola Night 10% carbamide peroxide gel. The take-home kits included 10 syringes, which last 30 days. 10% Pola Night is my whitening of choice due to being fluoride-releasing and having a high water content, which minimises sensitivity. In addition, the gel contains potassium nitrate, a known desensitising agent to help prevent any sensitivity. Using a lower concentration allows the teeth to gradually change colour, resulting in a longer shade satisfaction.
The patient carried out at-home whitening for a period of four weeks. She experienced some sensitivity and was recommended to use Pola Soothe for 45 minutes prior to whitening at night time to eliminate her sensitivity.
Figures 2 to 5 show how the colour of the teeth improves weekly. It is vital to inform patients they may see little change for the first week, and to get the best result, whitening should be carried out for a minimum of three weeks.
FIGURE 2: One week of whitening
FIGURE 3: Two weeks of whitening
FIGURE 4: Three weeks of whitening
FIGURE 5: Final result
Once the teeth have reached their ‘maximum whiteness’, they will not change any more and the patient can stop treatment.
Results
Overall, the patient was pleased with the results and maintained the colour of her teeth with a single-night top-up once a month.
Tooth whitening can be a great practice builder and income generator for practices when done correctly. The biggest challenge is patient expectations; however, if explained correctly, the patient and dentist can both be confident in the process.
References
Haywood VB, Heymann HO (1989) Nightguard vital bleaching. Quintessence Int 20: 173-176
Haywood VB (2000a) Supervised at-home bleaching is the safest and most effective. Dental Products Report 82-91
Haywood VB (2000b) Tooth whitening in your practice: treatment time and fee schedules. Contemporary Esthetics and Restorative Practice 4: 12-15
