1. Clinical & Legal Considerations Aidan Hannah
Tooth Whitening
Clinical & Legal Considerations
Aidan Hannah

2. Contents Introduction Legal Aspects Clinical Aspects Vital Bleaching
Non-Vital Bleaching
Alternatives
References

3. Introduction Increased prevalence – celebrities etc. Staining
Extrinsic – Dietary, Smoking, Chlorhexidine
Intrinsic – Developmental (Fluorosis, Tetracycline, Amelogenesis Imperfecta) Loss of Vitality

4. Legal Aspects GDC Indemnity/Insurance
Defined as ‘the practice of dentistry’
Dentists, Therapists, Hygienists & Clinical Dental Technicians
Ethical obligations as per any treatment
i.e. Act in patient’s best interest, obtain fully informed consent, have valid medical history
Indemnity/Insurance
Check with your provider – registration at risk if practicing without appropriate cover
Practice of dentistry – only GDC registrants
Ther/Hyg/CDT require prescription from dentist – ‘additional skill’
Nurses can take imps with additional skill
Different organisations can have different rules/levels of cover

5. EU Governance on tooth whitening products
EU Council Directive 2011/84/EU in effect from Oct 2012
18+ years old
0.1-6% Hydrogen Peroxide (present or released by other compounds)
To be sold only to dental practitioners, first use limited to them; can then provide access for patients thereafter
Effect of Brexit?
16% carbamide peroxide releases <6% hydrogen peroxide
First use by dentist/under direct supervision – demonstrate in chair
Advise pt’s of harm of buying from unregulated source
Brexit - Watch this space

6. Glasgow girl on FB recently – woman working from home, no exam/Qs etc
Glasgow girl on FB recently – woman working from home, no exam/Qs etc. Gel applied every 15mins for 1 hour
Numbness/swelling/pain/ulceration/burning sensation for days
GDH Dx 3rd degree burns/possible allergic reaction

7. Clinical Aspects Case Selection Thorough exam first
Anterior restorations?
Predictable outcome?
- acquired/mild developmental stains
Vital vs Non-Vital
Informed Consent
- contemporaneous notes
Wait ~1 week after finishing before commencing any restorative work involving bonding
Severe discolouration/extensively restored prob better with restorative option
Consent – other options, risks (sensitivity, transiently white gngivae), benefits (conservative of tooth tissue), costs, lifespan of result (1-3 years), effect on restorations – may need replaced afterwards/trays may not fit again after this
Main side-effect is sensitivity due to pH opening dentinal tubules. Effects usually short-lived

8. Treatment Options Vital Bleaching At home using vacuum-formed splint
Indicate extensions eg. to distal of 6s
Worn for 2-3 hours/8 hours depending on product
Demonstration by dentist first
Matchstick-head size amount on labial aspect of tray (Most commonly carbamide peroxide)
Usually results within 2 weeks, although could take longer - review
Take shade at start/finish

9. Patient Information: Brush teeth first
Wear 2-3hours/8hours (overnight) depending on product
Apply matchstick-head amount to labial aspect
No eating/drinking during wear
Rinse with water after
Use sensitive toothpaste – if sensitivity occurs, use on alternate nights
Minimal contact with red wine/coffee/tobacco to prolong effects

10. Non-Vital Bleaching
Good option if only 1 tooth discoloured/tooth minimally restored – avoids use of more destructive restoration
GP removed to below gingival margin, sealed
Bleaching agent (most commonly sodium perborate) packed against labial wall, sealed in with temporary restoration for 2 weeks
Repeat until desired shade reached
Some etch pulp chamber first, however no evidence to support efficacy

11. Alternative Treatment Options
Micro-abrasion (superficial only)
Scale & Polish (surface stains)
Permanent restoration
Leave alone...

12. References Advanced Operative Dentistry. D.Ricketts & D.Bartlett