techniques article WHITER, BRIGHTER, HEALTHIER SMILES ASSISTANT FOR THE CHAIRSIDE of Indications In-Office FREE 1 Topical Fluoride CEU COURSE CREDIT! Treatments: Varnish, Foam, and Gels By Shannon Pace Brinker, CDA CDD • CPS Magazine www.cpsmagazine.com W 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 from Pace Heraeus and SDI. We chose, patients varying ages and used differing methods for predictable results. by systems Shannon Brinker, CDA CDD,ofEditor in Chief, Contemporary Product Solutions • www.cpsmagazine.com HOW DOES WHITENING WORK? 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 the history, efficacy, and indications for three Academy and Spear Introduction PRODUCT TYPES Education. She is an types of topical fluoride treatments. There aremember three basic types of whiteningAprocedures our office offers; they are: demonstrated active of the study conducted in the 1990s, AACD. Shannon is whitening) the • In-Office (one-hour with take-home a steadytraysrate of decline of instances of first auxiliary to sit on thewhitening) Day or Evening wear • Take-Home (custom tray coronal caries through the 1980s. This Varnishes (Sealants) AACD Board of Directors. • Pre-Filled (disposable trays)decline was attributed to an increase in oral Shannon was selected whitening one Sodium Fluoride (NaF) varnish was first of Dentistry Today’s Top health education regarding diet and oral introduced in the United States in 1964.7 The 100 Clinicians of 2009, 1 hygiene, TRAYS and an increased awareness about PRE-FILLED, WHITENING 2010, 2011 andDISPOSABLE 2013. first generation available was a yellow-colored The Venus Ultra by tray that pre-filled with an 11.2% mint-flavored hydrogen peroxide gel that is worn for one hour a day for up the benefits ofis applying fluoride-containing She was White also selected as Heraeus is a disposable resin considered the tray standard of care 25 to Dental seven days. EachReport set comes and lower tray that self-adheres the toothsealants arches with just a pinch. This pre-filled is for teenagers andfor young Products 25 with an upper topical treatments such as todental years. The next generation available was a adults are looking forina lighter, brighter smile. mostwho influential women (i.e., varnishes), foams, or gels to the teeth of whiter, tooth-colored resin, which was slightly dentistry and Dr. Bicuspid’s individuals of all ages in moderate-to-highDental Assistant Educator more costly, but preferred by some patients. The risk groups for caries.2-6 This article reviews of the year for 2012. She third and most recent development was a clear/ is the Editor in Chief for transparent variation, making varnishes viable Contemporary Product Solutions and consultant for 1 for use with bleaching procedures. many dental manufacturers. For information on dental The primary indications of varnishes are as part of assistant programs, please a caries prevention program that includes other contact her at 757-285-9477 topical fluorides, such as toothpastes. However, or email at in 1994 the Food and Drug Administration shannon@cpsmagazine.com. Venus White Ultra 11.2%. Figure 1–Dry teeth with a cloth or paper towel before placement of the Venus White Ultra. Remove from packaging and place strip on upper teeth. 2012 SELECT 18 Fax Your Order: Figure 2–Mold the Venus White Ultra granted approval pre-filled strip to the arch form desensitizing agent of the upper arch. 3–Moldvarnish the Venus White of Figure fluoride as Ultra a strip to 7the arch form andpre-filled cavity liner. of the lower arch. Varnishes are clinically proven to provide at least 25% caries prevention in moderate-to high risk children, adolescents, and adults when applied between 2 and 4 times annually. Varnishes are 1.800.732.7023 24 Hours 3 Figure 1. Peel Back the blister pack of Profluorid Varnish (VOCO) in Carmel flavor. Figure 2. Take Brush and place in varnish. Figure 4–Retracted view of the Venus White Ultra in place on the maxillary and mandibular arches. 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. Figure 3. P lace Profluorid varnish on all teeth and instruct patient to close and move saliva Figures 6 and 7–Before and after, using the Venus White Ultra for 7 days. around teeth to moisten varnish. Instruct patient to avoid alcohol, brushing and flossing for 4 hours. FABRICATION FOR WHITENING TRAYS There are several materials to choose from when it comes to the impressions for the whitening trays. In my practice we use both polyvinyl and alginate. What is very important is the 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 the only topically fluoride the calcium and calcium deposits. The whenalso fabricating a whitening tray. Isapplied it necessary to cut the ion, papillatogether to minimizewith tissue irritation? From myions own experience in performing over 400sodium whiteningfluoride 8 procedures within the last 2 years, it has no difference whether the block or papilla has been removed the tray. The choice is really the patient. treatments recommended formade all ages. accumulated inoutthe tubules, causes a from works immediately whileup to the calcium We offer several types of whitening in our practice. When discussing compliance with the patient, it is very important to help the patient to understand that this is precipitation of calcium fluoride, which deposits store and release fluoride over The typeand of varnish depends an investment we do notchosen want to waste theirlargely time if they are not going to follow-up. In our practice we have nighttime wear and daytime wear. We allow the effectively seals the tubules. According time which makes it the perfect formula patient to choose, which makes them accountable. Poladay by SDI home-tray whitening gives the patient the option of a 30-minute whitening at 9.5%. We also offer on the patient’s age, setting in which they the patient a polanight that is an overnight wear carbamideto peroxide gel survey, at 10%. Teeth-whitening gel will only whiten teeth. and long term results. a user over 85 % of patients for natural immediate techniques article 2 receive the varnish (i.e., public program or private dental practice), patient were completely free of pain after only The perfect formula for immediate and preference, and whether a whitening one treatment with Profluorid Varnish. long term results. Profluorid L is free As well as rapidly sealing the dentinal from colophony, glutaraldehyde, gluten procedure is performed. tubules, Profluorid Varnish colophony, or methacrylates. Profluorid Another photo Profluorid Varnish (VOCO, Briarcliff L can be used after cleaning procedures, for this? also causes calcium fluoride deposits to Manor, NY ) is an easy to apply version cervical hypersensitivity, periodontal of the second-generation varnishes form on the tooth surface. These deposits treatment, after occlusal adjustments, available in single doses. Also containing protect the tooth from acid attacks, sensitive margins, before provisional are 5% sodium fluoride, this tooth-colored promote remineralization and contribute to seated, sensitivity from bleaching. Figure 1–Make sure trays are clean and Figure 2–Remove syringe from case and load Position tray over your teeth and gently press varnish is naturally sweetened with the long-term formation of fluoroapatite. dry prior to applying SDI Poladay 9.5% the tray with SDI Poladay 9.5%, depress the tray to move the gel into place. Do not press too Xylitol. While the primary indication Xylitol, which hasplunger, a proven cariostatic and fill each tooth in the tray with a hard—only enough to seat on teeth. Wear tray Foams is treatment of sensitivity, it is equally effect in addition pearl to its taste-enhancing of gel. One syringe will be used for two for 30 minutes a day from 10 to 14 days. Remove days ofto whitening or two applications of top trays after 30 minutes. Brush teeth and inside of effective in caries prevention. Profluorid properties, is also added the varnish In 1993, Sodium Fluoride (NaF) foams Whiter Brighter You and bottom. whitening trays to remove access material. Varnish adheres well to wet surfaces were introduced to the United States unlike most varnishes where teeth must market. These fluoride foams only be dry before application. It is a tooth Clear 5% Sodium Fluoride underwent a short evolution and include shaded and available in four great tasting Liquid Varnish’s acidulated phosphate foam (APF) for flavors: melon, cherry, mint and my deep infiltration, and neutral fluoride foam favorite carmel. Comes in a blister pack Profluorid L Varnish (VOCO, Briarcliff for restorations or individuals sensitive to Manor, NY) is a clear liquid thirdcontaining a brush and the varnish. generation varnish specially formulated to acidic fluorides. Neutral foams provide not interfere with bleaching procedures. fluoride without damage to the surface of restorations and are a good alternative for Components and effect of This varnish is indicated for a host of other acid-sensitive patients. Figures 3 and and after full face. sealing applications as4–Before well and including VOCO Profluorid Varnish the surfaces of damaged teeth and has Indications for fluoride foams are Profluorid Varnish is a colophony-based effective double protection of 5% sodium similar to other topical fluorides (i.e., varnish containing 5 % sodium fluoride fluoride and calcium deposits. Effective desensitization and cavity prevention), (22,600 ppm fluoride). The fluoride double protection of 5% sodium fluoride but they are most effective in primary Figure 4. P lace a few drops into the mixing well and stir with brush 4 5 Figure 5. P lace on areas that are sensitive from whitening 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 teeth andWHITENING on the proximal surfaces. Recommended mainly IN-OFFICE 9 Dental team members can help their patients decide if topical application would be beneficial, acknowledging for children, one study states way thattoall agesteeth. canVenus benefit from a anfluoride In-office bleaching provides the quickest whiten White Max is in-office whitening treatment that consist of a 38% hydrogen peroxide gelthat that is applied for 2 (30) minute sessions without the use of a light. The is instructed after the in-office whiteningfor to follow upmost the treatment with 2 weeks of take-home with low-risk caries likely would not benefit. 4-minute application of fluoride foam instead of apatient gel, since the patients whitening (One hour a day for 14 days or the patient may choose to have another in-office whitening procedure.). 10,11 foams are equally effective. These foams have been marketed as “minute-foams,” but just as with gels, a minimum 4-minute contact is recommended for adequate fluoride infiltration. Examples of neutral foams available are Topex Neutral Fluoride References Foam (Sultan Healthcare, Inc. Hackensack, NJ) and Kolorz 1. Rozier RG, Beck JD. Epidemiology of oral diseases. Curr Opin Neutral Fluoride Foam (DMG America, Englewood, NJ). Dent.1991;1(3):308-15. Acidulated phosphate fluoride foam is available in products like 2. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride gels for Denti-Foam Topical Fluoride Foam (Medicom USA, Augusta, preventing dental caries in children and adolescents. Cochrane CA). These foams claim deeper fluoride infiltration and lengthier Database Syst Rev. 2002(2):CD002280. fluoride retention in saliva after treatment. 3. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride gels for Foams provide an average 25% caries reduction rate in preventing dental caries in children and adolescents. Cochrane Figure 2–Pre Op Shade Tab D3 adolescents and adults with moderate-to-high-risk for caries.12 Database Syst Rev.2002(3):CD002279. Patient’s teeth have been pumiced. Retractor and Since foams are most effective on primary teeth, these rates can gingival barrier have been placed. be much higher—up to 41%—in the children in moderate-to- 4.Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels, or varnishes) for preventing 13 high-risk populations. Venus White Max Gels caries in children and adolescents. Cochrane Database Syst Figure 1–Full Face Pre-Operative Rev.2003(4):CD002782. Photo with Shade tab. 5. Rozier RG. Effectiveness of methods used by dental professionals for the primary prevention of dental caries.J Dent Educ.2001;65(10):1063Fluoride gels became available for use in the United States as 72. early as the 1960s. Like foams, they are available in neutral and acidulated phosphate fluoride (APF) compounds. Gels are 6. Van Rijkom HM, Truin GJ, van’t Hof MA. A meta-analysis of usually only recommended for use in older children, adolescents, of clinical studies on the caries-inhibiting effect of fluoride gel and adults to reduce the risk of swallowing, but gels can be treatment. Caries Res.1998;32(2):83-92. applied with a toothbrush instead of the standard tray method 7. D ental Products Report. Hygiene Article. Making the case for to further reduce this risk.14 fluoride varnishes. http://www.dentalproductsreport.com/hygiene/ article/making-case-fluoride-varnishes. Accessed April 5, 2013. The indication for fluoride gel is limited to caries prevention or reduction. Many dental professionals prefer the highly acidic 8. Q uock RL, Warren-Morris DP. Fluoride varnish: the top choice for APF gels due to their supposed higher fluoride uptake and professionally applied fluoride. J Mich Dent Assoc.2011;93(5):42-8. higher saliva retention after treatment. However, studies confirm 9. J iang H, Bian Z, Tai BJ, et al. The effect of bi-annual application of that neutral fluoride gels areProequally effective and not30have Figure 3–Mix the Venus White 38% hydrogen Figuredo 4– After minutes, suction off whitening 5–Suction off Venus White Max and rinse. APF foam on dentalFigure caries increment in primary teeth: 24-month 5 the ability to etch restorative materials do. peroxide gel. Apply 1 mm of Venus White Maxlike gel APFs agent and reapply for another 30-minute session. Remove the gingival barrier and retractor. Take a clinical trial. J Dent Res.2005;84(3):265-8. final photo and instruct patient on the use of the to facials of teeth for 30 minutes. Examples of available fluoride gels include Zap Fluoride Gel trays. 10 .Wei SH, Hattab take-home FN. Fluoride retention following topical (Sultan Healthcare, Inc. Hackensack, NJ), Phos-Flur Fluoride application of a new AFP foam. Pediatric Dent.1989;11(2):121-4. Gel (Colgate/Polmolive, New York, NY), and Sensodyne ProSchmelz Fluorid Gelee (GlaxoSmithKline Consumer 11. Wei SH, Hattab FN. Enamel fluoride uptake from a new APF foam. Pediatric Dent.1988;10(2):111-4. Healthcare, Brentford, Middlesex, United Kingdom). merican Dental Association Council on Scientific Affairs. Fluoride gels provide an average 25% caries reduction rate in 12. A Professionally applied topical fluoride: evidence-based clinical moderate-to-high caries risk groups, similar to foams and RESOURCES: 15 recommendations. J Am Dent Assoc.2006;137(8):1151-9. varnishes. References Conclusion 13. E vans D. APFand foam does reduce caries inVital primary teeth. Evid Based 1. Haywood VB. Tooth Whitening: Indications outcomes of Nightguard Bleaching. Hanover Park, Il: Quintessence Publishing Company Inc; 2007. Dent.2007;8(1):7. 2. Matis BA. Tray whitening: what the evidence shows. Compend Contin Educ Dent. 2003; 24(4A):354–362. 14. Ribiero CC, Lula EC, Azevedo IM, et al. Salivary retention after 3. Gottardi MS, Brackett MG, Haywood VB. Number of in-office light-activated bleaching treatments All three topical fluoride treatments—varnishes, foams, and application of fluoride gel using toothbrush or tray: a crossover trial. needed to achieve patient satisfaction. Quintessence Int. 2006;37(2): 115–120. gels—reviewed in this article provide at 4.least 25% caries Brazappraisal: Oral Res.2012;26(6):493-7. Browning WD, Swift EJ. Critical comparison of the effectiveness and safety of carbamide prevention in moderate-to-high-risk groupsperoxide of all whitening ages. This agents at different concentrations. 15. W hitford GM, Adair SM, Hanes CM, et al. Enamel uptake and Restor 2007;19(5):289–296. means that it is not a question of if patientsJ Esthet at risk forDent. caries patient exposure to fluoride: comparison of APF gel and foam. Cooper JS, Bokmeyer should use topical fluorides, but how often5.and which type. TJ, Bowles WH. Penetration of the pulp chamber by carbamide peroxide bleaching Pediatr Dent.1995;17(8):199-203. 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. 7. Hall DA. Should etching be performed as a parta Figure 7 Final Fill Face Photo of a vital bleaching technique? Quintessence Int. 1991;22:679–686. 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 10. McKamie A. Deep one practice’s protocol for enhanced a patient satisfaction. verifying 1 CEU Credit. To take the test andbleaching: receive credit, or request sample please go Contemporary Esthetics. 2007;10:12–19. to http://cpsmagazine.com/one-ce-credit-topical-fluoride-treatments 20 Fax Your Order: 1.800.732.7023 24 Hours