ANALYZE YOUR OWN SMILE

1. Do you have any concerns about your smile?

2. Do you cover your mouth with your hand when you smile or talk?

3. Are some of your teeth darker than the others?

4. Do some of your teeth have white or brown stains?

5. Are you self-conscious about smiling in front of other people?

6. Would you like a whiter, more youthful smile?

7. Do you see any defects in the appearance of your teeth or gums?

8. Are there spaces or gaps between any of your teeth?

9. Are your teeth crowded?

10. If you have crowding or spaces, is it getting worse?

11. Are any of your teeth too long or too short?

12. Are any of your teeth crooked, jagged, worn, or chipped?

13. Do you have old fillings or bonding that are chipped, discolored, misshaped,

worn, or otherwise in need of upgrading?

14. Do you have old veneers or crowns that need upgrading?

15. Do you have missing teeth that you would like replaced?

16. Is the appearance of your smile out of balance from one side to the other?

17. Is there anything else about your teeth or your smile that you would like to change

if it were possible?

If you answered “Yes” to any of these questions, you may want to discuss your

options for cosmetic dentistry with us. Call us for a consultation at (860) 537-2351 or

email us at info@ColchesterDentalGroup.com

What’s the biggest problem withtooth whitening? If you answeredanything other than “Sensitivity!”

you haven’t been paying attention. What’sthe second biggest problem? Compliance!The question is, “Why?” I suggest there are2 reasons: the first is obviously sensitivity;the second is the patient’s inability to appre-ciate that anything significant is beingaccomplished. In this article I will addressboth of these challenges and make manysuggestions as to how we have successfullydealt with and/or prevented these issues inmy office.

SOLVING THE CHALLENGES: COMPLIANCELet’s start with patient compliance. Ifpatients could see the results happeningright in front of their eyes, they would bemore pleased and would certainly be morecompliant. That’s only human nature. Weare all more likely to follow someone’s sug-gestion if we see proof that it is working.

Take-Home BleachingMost dental offices are still doing toothwhitening treating both arches at the sametime. Unless there is an extreme time dead-line, I never do that. We do a few otherthings differently also, and we are about toexamine each of them.

First, make what you are doing impor-tant. Take pre-op photos, and plan on mid-way and post-op photos also. Take a pre-opshade. Establish realistic expectations.Then quote a longer treatment time frame.In my office we say, “The average treatmenttime is about 2 to 3 weeks for the upperteeth, and another 2 to 3 weeks for the low-ers, but it’s possible yours could take a littlelonger.” Set your fee so you don’t have to

increase it if you need a little extra time orsome extra materials. Then you can promiseto “stick with it” even if this patient is aresistant case, and you are a hero if it takesless time to get the desired results.

Bleaching TraysGet accurate impressions to fabricate yourtrays. (We use a polyvinyl alginate substi-tute). Remove all bubbles from the modelsto make sure that you have sharp gingivalmargins and clear occlusal surfaces foraccurate seating of the trays. Most officesare using scalloped trays so that the trayroughly follows, but does not touch, the gin-gival margins. Unfortunately, this methodallows excess whitening material to escapeinto the mouth, and often leaves no whiten-ing product at the gingival margins. Since

this is the darkest part of the teeth and thehardest to whiten, why would one want toallow less material to be held there?Therefore, a different design is required. Inour office, we end the buccal margin of ourtrays in a straight line approximately 2 to 4mm beyond the zenith of the gingival mar-gin (Yes, that’s right, on the gingival tissue.)

We also use reservoirs. Certainly, I haveheard the same statements that you have—that reservoirs are unnecessary—but thatjust doesn’t apply to this technique. (If youhave a scalloped edge, those statements arecorrect: reservoirs don’t matter because thegel is going to escape no matter what you dosince the tray can not be well enough adapt-ed to the teeth). However, since we havesealed the gingival margin of the tray

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Martin H. Zase,DMD

First, make what you are doingimportant. Take pre-op photos,and plan on midway and post-opphotos also. Take a pre-op shade.Establish realistic expectations.

The ProblemsWith ToothWhitening:Preventing SensitivityWhile ImprovingPatient Compliance

Figure 2. Block out added.Figure 1. Upper model.

Figure 4. Reservoir tray showing gingival extension.Trays like these hold the bleaching gel intimately againstthe entire buccal surface of the teeth, but because themargin of the tray is extended on to the gingiva, there isno leakage at the gingival margin.

Figure 3. Tray on model.

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against the gingival tissue, makingreservoirs to hold the whitening gelagainst the teeth makes perfectsense. We place a thin layer of light-cured blockout material on the buc-cal surfaces of the teeth to bebleached. Then, we vacuum form atray over the model and use a heatknife to cut the flat margin againstthe gingiva (no blockout there).Next, we smooth the cut tray edge byslightly heating it with a flame andthen pressing it with a sliding fingeragainst the stone model. The resultis a pocket that holds the bleachinggel completely against the buccalsurface of the teeth and dispersesthe gel right up to (yet stopping at)the gingival margin. In this way, thewhitening gel is kept exactly whereit needs to be during the entiretreatment time. In the rare instancewhen the patient gets sensitive gin-gival tissue, the tray is cut back inthose areas into the more commonscalloped shape (Figures 1 to 4).

(Here is a challenge to try onyourself: Take an impression of yourown mouth and make a bleachingtray. Construct one side as describedabove with block out, reservoirs, andthe tray edge a few millimeters upon the gingiva; and then fabricatethe other side in the “normal” [noreservoir, scalloped edge near thegingival crest] way. Put somewhitening gel in the tray, insert itinto your mouth, and look in the mir-ror. Watch the gel ooze out of thescalloped side. If you need furtherconvincing regarding this design’sadvantages, go ahead and use it per-sonally for a couple of weeks. Youwill have to go back and help thescalloped side catch up to the “bet-ter-bleached” side done with the traydesign fabricated using this method.You will be absolutely convinced ofthe effectiveness of this method.)

Bleaching ProtocolWe then deliver only the upper tray,giving instructions, and asking thepatient to return in one week for acheck of how they are doing. If theyhave any problems in the meantime,they are to call and return to theoffice immediately. Within a week,the patient can see a differencebetween their upper and lowerteeth. As each day progresses, theycan see an even greater contrast. Ifboth arches are done at the sametime, the daily difference is too sub-tle for most patients to discern, sothey may perceive this as noimprovement and gradually quit. So,you can understand how you haveultimately caused their noncompli-ance in this way.

After the one-week check, wethen (usually) have the patient

return 2 weeks later. The ever-increasing contrast between thearches in our patients, they have theincentive to keep bleaching asinstructed so they can get the lowertray (which we withhold until weand the patient feel they havebleached to the desired level) as soonas possible. At this point, the patientwill be a great ambassador for youroffice. They typically show everyonehow becoming brighter and moreattractive and explain how you havehelped them accomplish this goal.We then take a mid-treatment photowith the upper teeth white and thelower teeth unbleached (Figure 5).The lower tray is then delivered. Thepatient is brought back once againfor one week to monitor the progressof the lower teeth, and then typical-ly a final check, 2 weeks later. At thisfinal check appointment, post-opphotos are taken. The patient isreminded that touch-ups are inex-pensive and are expected at about 6month to one year intervals. (“Whynot plan on it at each ‘cleaning’appointment?”) With this method,you will get compliance, and yourpatients will get whiter teeth for life.

SOLVING THE CHALLENGES:SENSITIVITY

A significant number of patientsdevelop temperature sensitivity dur-ing the whitening process. First,reassure them that it is transient. Italways goes away within a couple ofdays of discontinuing the bleaching.Some patients develop such intensesensitivity that they would ratherstop the process than to put up withthe discomfort.

Chemical TreatmentsThere are many methods for dealingwith sensitivity. One of the firstmethods was the use of fluorideapplications, either in the trays or inprescription-level fluoride tooth-pastes. Potassium nitrate is anexcellent desensitizer and is of enor-mous help. More recently, amor-phous calcium phosphate has alsoproven to be quite an effective addi-tive. All of these chemicals help toreduce bleaching-related sensitivity.They have also been incorporated inmany of the currently availablewhitening products.

Preventing SensitivityHow about preventing the sensitivi-ty in the first place? In my opinion,dehydration is the primary cause ofwhitening sensitivity. Picture yourlast visit to the hygienist. They aretrying to be extra careful and toremove even those tiny little specksof calculus just subgingival on thelingual surfaces of your mandibular

anterior teeth. Then they blow someair on the area to better visualizethe calculus, and then blow a littlemore. The teeth are dried out andthey give you a “zing”—which youinterpret as sensitivity to cold.When we bleach, the evaporation ofthe nascent oxygen produced fromthe peroxide dehydrates the teeth.That is why the teeth always look alittle chalky right after bleaching—they are dehydrated.

To solve the dehydration prob-lem, we use a prewhitener (PowerSwabs [Power Swabs Corporation])that performs 3 functions. First,Power Swabs include solvents thathelp clean the teeth (like prewashstain removers help in cleaning grassstains off trousers). It doesn’t take arocket scientist to realize that cleanteeth should get whiter faster thandirty teeth. Second, since there isless debris on the enamel, the bleach-ing can penetrate deeper—againresulting in faster and greaterwhitening. Third (and most impor-tant), the swabs contain a surfactant(wetting agent). The surfactantallows the bleaching gel to dissipateall over the teeth keeping themhydrated, and since the teeth are notallowed to dehydrate (keep bleachingtimes short) the teeth do not get sen-sitive. Thus, the simple use of thisprewhitener produces results thatare whiter and faster while eliminat-ing a main cause of sensitivity.

Prewhitener TechniqueThe Power Swabs prewhitenercomes in a tube within a tube appli-cator. Slide the lower tube up overthe upper tube, and it soaks theswab at the end (Figure 6). Then, allit takes is to apply the soaked PowerSwab with a swirling motion on thesurface of the teeth for 30 secondsimmediately before applying thewhitening agent (Figure 7). Sincethe prevention of sensitivity islinked to the ability of the surfactantto keep the teeth hydrated, the sen-sitivity-prevention trait diminisheswith the amount of time the whiten-ing agent is in contact with the teeth.Thus, the swabs work with shortduration whitening procedures, andI have not found them to be veryeffective for overnight bleaching.

So, let’s go back to compliance fora moment. If you can show thepatient that their teeth are gettingwhiter, and they can see it every day,and their time of application isreduced, and they have no sensitivity,why wouldn’t they do what you ask tohelp them improve their appearance?

POWER BLEACHINGThe good news is that theprewhitener also works extremely

well with power bleaching. Whetheror not you use a light source, powerbleaching involves a dental profes-sional applying a stronger whiteningagent for a shorter period of timethan when using trays. To shortenthe time even more while improvingthe results, just swirl the soakedPower Swab all over the surfaces to

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MARCH 2009 • DENTISTRYTODAY.COM

Figure 5. Midbleaching documentation photo.Upper teeth have been completed; the lowerteeth are yet to be done.

Figure 6. The applicator.

Figure 7. Applying a prewhitener with asoaked swab (Power Swabs [Power SwabsCorporation]).

Figure 8. Before whitening.

Figure 9. After whitening.

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be bleached for 30 seconds immedi-ately prior to each application. I typ-ically cut my time for application ofthe whitening agent down to 3 setsat 10 minutes each. It is amazing,but when the final coat is rinsed offwith cold water, the patients do notwince because the prewhitener pre-vented any sensitivity.

I typically follow power bleach-ing with a week of take home traytreatment, still using the prewhiten-er before every application. For max-imum compliance, you can use theone-tray-at-a-time method, but Ionly do in-office power bleaching forthose who are in a hurry—so theyusually get both trays at once.

In rare instances, a few patientsstill get a little sensitivity with 30minute tray applications of peroxidewhiteners at home. If this happens, Ijust reduce the time to 15, or even 10minutes, and have the patient takeone day off. This does extend the totaltime to get the whitening results wedesire, but at least we can bleachthese folks who would otherwise beunwilling to complete the process.

SUMMARYSo there you have it—a system toguarantee compliance and to elimi-nate the sensitivity that often accom-panies bleaching treatment. Give thepatients control so they can see andcelebrate their improvement (Figures8 and 9). Most importantly use a pro-tocol and methods that get the jobdone faster and better with anabsolute minimum of discomfort.�

Dr. Zase practices general dentistry with anemphasis on cosmetics, at the ColchesterDental Group in Colchester, CT. He is anaccredited member and past president (2006-2007) of the American Academy of CosmeticDentistry. He is also a master of the Academyof General Dentistry. He can be reached at(860) 537-2351 or Martyzase@aol.com.

DISCLOSURE: Dr. Zase is the professionaladvisor for Power Swabs Corp, the manufac-turer of the Power Swabs.

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Dr. Marty Zase 860.537.2351

How to get ZERO sensitivity

with trays

THE MATERIALS

Vita

Bleachguide

3D-Master

Hydrogen Peroxide

for daytime use

WITERx

WITERx.com 7.5% Hydrogen Peroxide

5% Potassium Nitrate

0.25% Fluoride

Pre-White

Swabs 855-55-SWABS

www.WITERx.com

Use reservoirs

Extend borders to seal the whitening

agent against the teeth

.040 soft tray material

Make sure you trim or flame off all rough edges

3 - 4 mm.

Use short duration applications (days)

Use a pre-whitener before every application (days)

Do not scallop the margins

Use reservoirs

Construct accurate trays

Use short duration applications (days)

Use a pre-whitener before every application (days)

Do not scallop the margins

Use reservoirs

Construct accurate trays

breaks down slowly like a time release pill

Nite White is Carbamide Peroxide

so is used overnight

WITERx and Day White

are Hydrogen Peroxide = H2O2

They work immediately but are

only active for a short time.

So they are used during the day for 30 minutes

Carbamide Peroxide at night (active ingredient is only one-third)

.

10% carbamide (Nite White) = only 3% H2O2

7.5% H2O2 (WITERx) = 22.5% carbamide

.

Hydrogen Peroxide for daytime

Hydrogen Peroxide during the day (half hour maximum per session)

Carbamide Peroxide all night

How to get ZERO sensitivity

with trays

PROTOCOL

Deliver the upper tray and plan on seeing the patient

after one week unless there is a problem.

Then plan on seeing them 2 weeks later. Repeat if needed.

Once there is sufficient shade change, deliver the lower

tray and follow the same timetable for the lower.

Take shades and photographs for documentation:

1) At the start before any bleaching

2) At the midpoint

3) At the end

Take shades and photographs for documentation:

(now available in the US)

SHOFU

Eye-Special C-II

Super easy to use and the

best camera for bleaching documentation

Start with night time first unless:

Wearing a night guard

Wearing orthodontic retainers

Already complaining of sensitivity

Patient won’t comply

If patient has sensitivity…

STOP and come see us!

Switch to daytime …

Use Pre-White Swabs

Start with 15 minutes

STOP !

Skip the next day.

Reduce the time when you resume.

If ANY sensitivity with daytime…

If there is still sensitivity…

Utilize Pronamel in the trays

For 10 minutes before using the bleach

And 10 minutes afterwards

If there is no sensitivity…

Increase the time of application

by 5 minutes a day to a maximum of

30 minutes at a time twice a day

Try it on yourself

Then try it on your patients

Then try it on your staff

Let your patients know

what YOU can do.

Email --- SolutionReach

Talk to them!

Direct mail, newspapers, website

Send thank you notes to

Martyzase@aol.com