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today IDEM Singapore April 10, 2016

n Many people quest after a sparkling white smile, but what is the reason? Is it because a smile is an essential asset for to convey health and beauty and is essential for all forms of communication in oursociety?Abeautifulwhitesmile helps patients to feel confident to facetheworldandtofeelgoodabout themselves, which then improves their self-confidence, and self- esteem. While a sparkling white smileisdesirableforsome,itiseven essential for others. It has been shownthatpeoplewhohaveagood smile,whiteteethandlookpresent- ableinaninterviewgetofferedjobs quicker as they make a better im- pression. Tooth whitening is therefore one of the most requested services amongst patients, more than any other dental treatment service. It is thus essential that dentists are ready to receive many enquiries about the procedure and take extra efforts to train on tooth whitening techniques. Aesthetic dentistry The demand for aesthetic den- tistry has increased exponentially over the last decade. There is a wide range of treatments available which can be undertaken from a minimal invasive perspective. The key is to preserve as much healthy enamel as possible and enhance thesmilethroughwhitening,micro- abrasion and direct composite bonding. While porcelain laminate veneers revolutionised smile cre- ationbackinthe1980s,theystillre- quired some type of preparation of healthy teeth. Nowadays, methods involving porcelain and compos- ites used for veneers use a minimal invasive approach and in most cases not touching the healthy enamel. Treatment options in aesthetic dentistry • Tooth whitening. • Microabrasion to remove white spots from teeth. • Icon resin Infiltration to remove the appearance of white marks and white patches on teeth. • Directbondingontoteethwithno preparation. • Advances in Straightening teeth includes many new options for Orthodontictreatment.Theintro- ductionofalignertreatmentwith- out the use of metal braces. In ad- dition, there are now porcelain brackets, white wires and the use of lingual orthodontics. Clear alignertreatmentishardlynotice- able on teeth and whitening can beundertakeninthealignertrays whiletheteetharebeingstraight- ened. • Closing of spaces, midline di- astemas through orthodontics, composite bonding, • Improving smiles through creat- ingsymmetryandharmonyofthe smile. • Assessment can be undertaken through digital analysis of photo- graphs and imaging software to create a beautiful smile. • Combination of treatments (as above) can incorporate different treatment modalities to create a beautiful smile. Toothwhiteningtechniqueswere revolutionisedwiththepublication of a key research paper called “Nightguardvitalbleaching:effects on enamel surface texture and dif- fusion” by Quintessence Publishing in 1989. In this paper, the authors VanHaywoodandHaraldHeymann described the use of a bleaching tray to place the whitening gel into the mouth for better retention. This methodprovidedlongerlastingand morepredictableresults.Ithasnow been 26 years since that this paper was published. Millions of people around the world have benefitted fromtoothwhiteningmaterialsand techniques and its popularity still continuestogrow(Greenwall2001). Methods of tooth whitening Home bleaching There are two basic techniques for home bleaching using a car- bamide peroxide material (night time use), or a hydrogen peroxide only material (day time use). The numberofvisitsvariesaccordingto the severity of the discolouration. The general rule is that the darker the teeth is the longer it will take to whiten it. This will determine thenumberofappointmentsforthe patient. Power bleaching Itisveryrarethatonlyonepower whitening will provide sufficient long lasting results. If the teeth are power bleached this should nor- mally be followed by home bleach- inginordertoachieveadeeperpen- etration of the whitening gel over a longer period of time. Maybe multi- ple visits of power whitening at cer- tain intervals are required. Power bleaching is not a one off procedure. Patients should be in- formedaboutthis,sotheyhavereal- istic expectations of what can be achieved during one single session. Often power bleaching is under- taken as maintenance treatment af- ter a hygienist visit depending on the white shade that the patient wishes to maintain. Home bleaching visits For patients who only require a basicwhiteningoftheirteeth,itmay take approximately two weeks of home whitening of the upper and lower teeth. Most home bleaching programmes require six appoint- ments.Thefirstappointmentisusu- ally to undertake a thorough evalu- ationandtoexcludepathologyfrom the mouth. In the second appoint- ment the dentists explains the pro- cedureaswellastherisksandifthe patient gives consent, impressions are taken for bleaching trays. The third appointment is for delivering thebleachingtraysandtocheckthe fit. Normally only the upper teeth are whitened first. The fourth ap- pointment is to review the upper whitening and to rule out any side effects. If the whitening was suffi- cient,thedentistcancommencethe lower whitening which is assessed in a fifth appointment. The sixth appointment is for the final assess- ment of the shade after the upper and lower whitening is completed. Before and after photos are taken for comparision. Studies have demonstrated that using the original protocol of Van Haywood (Haywood 1991 a, b, c) whereby for a basic whitening case the total treatment time is about 4 to 6 weeks. Normally, the upper teeth are whitened first for a pe- riod of at least two weeks, then re-assessed. Then upper and lower whitening may take place together for one week and after that the lower teeth are whitened for an- other two weeks. The upper teeth may take two to three weeks to whiten. The upper teeth are whitened first as they whiten quicker and normally show less side effects like sensitivity. The patient has a comparison of the colour when only the upper teeth are whitening first. The lower teeth may take at least three weeks to whiten. They usually experience more sensitivity owing to the tray to be in contact with the lower pre- molar teeth as well as the cervical recession present on some teeth. There is believe that the agents are washed out on the lower teeth with the salivary duct so the whitening takes longer on the lower teeth. Bleaching single dark teeth With the introduction of whiten- ing techniques, the treatment op- tions for both vital and non-vital teeth have changed over the last 25 years. Nowadays, a sectional whitening tray can be used to whiten the single dark tooth whe- ther they are vital or non-vital. It is essential to whiten the dark tooth first. Otherwise the contrast to the rest of the teeth will be higher as normal teeth whiten quicker. Vital single dark teeth When the patient receives mild trauma to an anterior tooth (bleed- ing into the pulp chamber and canal), the tooth tries to repair and heal itself by laying down extra sec- ondary and tertiary dentine in the pulp chamber which causes dis- colouration. This can be seen when the tooth is a different colour com- pared to its neighbouring teeth by about oneor two shadesonly. Inthe pastitwasassumedthattheseteeth need to have root canal treatments (Haywood 2010). This however turnedouttobefalseandtheyneed only to be whitened. Non-vital teeth The techniques for non-vital bleaching have also evolved after sodium perborate was banned in response to concerns about its feototoxic and cytotoxic effects. The standard technique called the Walking Bleach technique used sodium perborate mixed with 35 per cent hydrogen peroxide. The two products acted synergis- tically and created the equivalent of 50 per cent hydrogen peroxide which is too caustic for a root canal considering that it may be affected byprevioustrauma.Theuseofhigh concentrations of hydrogen perox- ide has recently been banned in Europe and it is only be possible to use 6 per cent hydrogen peroxide sealedintoarootcanal. Inaddition, the strong concentrations of hydro- gen peroxide in combination with previous trauma to the tooth may result in cervical resorption (Cvek 1985, Hierthersay 1999) which has been extensively described in the literature. This treatment has been modi- fiedwiththeuseofableachingtray and a segmental bleaching tray. Nowadays, 16 per cent carbamide peroxide is sealed into the root canal. The patient uses the bleach- ing tray to whiten the external sur- face of the tooth, so it is effectively whitening from the inside and the outside of the tooth with the same technique. Amodificationwasdescribedby Dr Willie Liebenberg in 1997 where he advocated leaving the access cavity of the non-vital tooth open. Healsorecommendedthatpatients apply the whitening syringe di- rectly into the access cavity every two hours thereby whitening the news 6 IDEM Singapore 2016—10 April A sparkling white smile By IDEM presenter Dr Linda Greenwall,UK 1c 1b 1a 5 Fig. 1a: Teeth before whitening.—5 Fig. 1b: Advanced whitening case with a diagnosis of fluorosis. This patient had direct composite bondings placed over the upper central incisor teeth to mask the discolouration of the brown, orange and white markings. These bondings were removed with a soflex disc (3M) prior to whitening. Once the natural enamel was visible again and all the composite material had been removed back to the healthy enamel, home bleaching was undertaken with the help of a bleaching tray. First the upper teeth were whitened to get comparable results of the bleaching potential of the teeth. The patient was reviewed after the first phase which was after two weeks of home bleaching using 10 per cent carbamide peroxide. He was then again reviewed three weeks later. As the discolouration is advanced and complex, the patient was advised that it would take 8 to 10 weeks to whiten the teeth. The patient needs to be carefully monitored during the whitening treatment.—5 Fig. 1c: Teeth after whitening with carbamide peroxide for 8 to 10 weeks. 5 Fig. 3a: This patient had a basic inherent yellow grey shade of his teeth. His upper central incisors experienced trauma 30 years prior. At that time, the teeth were bonded.—5 Fig. 3b: The appearance of the upper teeth after whitening and before new bondings were placed on the teeth. Streaked white areas are present on the teeth during the whitening as the whitening gel has penetrated quickly in the incisal tips of the teeth. The patient is reassured that this effect is only temporary and will even out with further bleaching.—5 Fig. 3c: Teeth after whitening and the placement of new direct composite bonding on the upper central incisors and upper right lateral incisor. 3c 3b 3a 5 Fig. 2: Options for tooth whitening and additional minimal invasive treatments. TDI0816_06-07_Greenwall 05.04.16 13:47 Seite 6 TDI0816_06-07_Greenwall 05.04.1613:47 Seite 6

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