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news 7 IDEM Singapore 2016—10 April tooth over the course of the week- end.Thepatientwastoreturnatthe endoftheweekend.Theaccesscav- itywasdisinfectedandcleanedand the pulp chamber restored with glass ionomer. Tooth sensitivity Sensitivityisbyfarthemostcom- mon side effect which affects up to 85 per cent of patients. It can range fromamildawarenessoftheteethto athroborspecificacheononetooth. While for some patients it is just the teeth that are sensitive, for others it is the soft tissues and gingivae. Tooth sensitivity is manageable mostofthetime.Extensiveresearch has been conducted to understand how and why patients experience tooth sensitivity when undergoing tooth whitening procedures. For ex- ample, it was discovered that the whitening gel penetrates the tooth within 5 to 15 minutes after the ap- plication of the gel. Therefore, it is essential to assess the pulps in all teeth and ensure that they are healthy. This can be done by testing the teeth with a cold stimulus or an electric pulp tester. If whitening was to be undertaken in the pres- ence of a periapical lesion in a non- vital tooth, the affected area could flareupandrequirerootcanaltreat- ment. Furthermore, it has been found that oftentimes the patient is the most sensitive on the third day of traybleachingowingtothefactthat thereismaximumsaturationofoxy- gen inside the tooth at this time. The new generation of whiten- ing products also contains extra soothers such as potassium nitrate, fluoride and amorphous calcium phosphate.Patientsaregivensooth- ing toothpastes to use prior to and duringtoothwhiteningprocedures. Many of these contain remineralis- ing agents, enzymes, fluoride, cal- cium and phosphate, some contain Novamin and hydroxyapatite. Pa- tientsmayusethesetoothpastetwo weeks prior to bleaching to sooth any existing sensitivity. Patients are also given propri- etary soothing agents like Soothe (Southern Dental Industries, Aus- tralia) and Ultraeze (Ultradent, USA).Theseproductscontaineither potassium nitrate, fluoride or both. In addition, some products contain amorphous calcium phosphate for an additional desensitising effect. One of these products is relief gel from Philips Oral Health Care which is loaded in a double barrel syringe so it is mixed freshly every time. It is placed into the bleaching trays and the patients wears them for an hour before or after bleach- ing. If sensitivity is really severe, theymayskiponenight.Onereason explainingthesensitivityisthatthe whitening gel travels through the weakest part of the tooth which is often a crack. Tooth sensitising is always tran- sient and the patient is not left with permanent sensitive after whiten- ing treatment. Whitening maintenance If the protocol, described by Pro- fessor Van Haywood is followed precisely, the research has shown that the whitening can last up to 17years.However,somepatentslike totopuptheirwhiteningafterthree years. However, it is not necessary to top up whitening each month. It is essential that during the initial whitening treatment the bleaching potential of the tooth is reached ef- fectively. Once the bleaching poten- tialisreachedthenwhiteningmain- tenance only needs to be under- taken approximately three years later. When the patient re-whitens their teeth, they would whiten for a shorter period from 3 to 7 days. Considering the time period sincecontemporarywhiteningtech- niques have been introduced, it is expected that patients will whiten their teeth periodically to maintain awhitesmile.Normally,duringthis time the patient may whiten 4 to 5 times within a 27-year time span. Avoiding staining: Keeping your teeth clean? While maintenance is essential, theuseofwhiteningtoothpasteand sometimes the reduction in food anddrinksthatcausestainingisrec- ommended. Beverages that induce stains are black tea (without milk), herbal teas, fizzy drinks like cola, expresso coffee and red wine. Stain inducing foods are curries, spicy foods, soya sauce, some berries, beetroot, vinegar and fried food. There, the oil molecule penetrates thetoothstructurecausingabrown- ing reaction inside the tooth com- parable to when fried foods are cooked. Habits such as smoking cause black discolouration on teeth that is both intrinsic and extrinsic. Antibiotics also cause staining on the tooth surface but more com- monly antibiotics taken by patients cause intrinsic discolouration of teeth. For example, in patients who aretakinglowerdosesofantibiotics for treating acne (i.e. Minocycline), teeth can become grey. Dentists should discuss this with their pa- tients in order to have the medica- tion changed by their GP. Keeping a sparking smile re- quires maintenance. This included regularvisitswiththeoralhygienist as necessary, the use of an effective toothbrush to remove the superfi- cial stains. Some patients find that anelectrictoothbrushismoreeffec- tive at removing stains from teeth, but this can be up to personal pref- erence. A mouth wash can be effec- tive in improving oral health and can be used daily as recommended by the dentist. There is a new oral health maintenance technique which has been researched called “oilpulling”inwhichpatientsswish their mouth for 20 minutes with coconut oil. This is believed to re- ducesurfacesstainsandmaintaina healthy gingival environment. Con- troversially there are some prod- ucts on the market containing oils that claim to have a whitening ef- fect, but these products have been fined in the UK by the advertising standards authority for false ad- vertising. However, there are many of the new professional mouth- washes on the market contain oil as an ingredient to be able to utilise this ancient Ayurveda technique (Greenwall 2015). Whitening strips have been also used for whitening maintenance. They have been shown to be benefi- cial for whitening but are normally for removing basic discolouration from teeth rather than patients experiencing advanced discolou- ration such as deep tetracycline staining. Whitening strips should notbeusedmorethanonceadayas it may increase sensitivity. In the UK, the whitening strips are only availablebyprescriptionoftheden- tist. However, in the US whitening strips are freely available over the counter in drug store as well as supermarkets. The future of tooth whitening There are exciting new develop- mentsinthefieldoftoothwhitening like the introduction of whitening varnish (Philips Zoom QuickPro, Philips Oral Health Care). Here, the tooth is coated with a varnish con- taining 6 percent hydrogen perox- ide. This hydrophilic varnish ad- heres well to the tooth, delivering the active agent directly into the enamelanddentine.Ahydrophobic sealantlayerdriesonthetoothwith the aim to lock the hydrogen per- oxide layer in place. The two layers do not mix during application. The varnishisleftontheteethforhalfan houreachdayandthenitisbrushed off with a toothbrush. There are also new develop- ments involving enzymatic bleach- ing where tow products are mixed together to activate and speed up the process of whitening using a 3 per cent carbamide peroxide gel in combination with the enzyme lactoperoxidase. Controversies Patient expectations towards teeth whitening have increased to such an extend that most expect to achieve whiter teeth that are also perfect in shape and size in an in- stant. The demand for white teeth has also reached extreme levels in somepatients.Thereisaphilosophy of perfection that has crept into popular culture and there is a certain fashion trend associated withwhitening.Themediaportrays whitening as a must have treat- ment. Unfortunately, the advent of extreme makeover shows has led somepatientstodevelopunrealistic expectations of the outcome and what aesthetic dentistry can pro- vide. They expect that after 20 min- utes their teeth will be magically whiter. Achieving a perfect smile withperfectlywhiteteeth,however, isnotalwayspossible.Expectations need to be kept realistic and de- fined. Dentist should be able to ex- plain exactly the reasons for under- takingwhiteningtreatment,aswell as what patients can and cannot ex- pect from it. There is a time factor associated with tooth whitening. The darker the tooth, the longer it will take to whiten it. Not all teeth can be whitenedwithintwoweeks.Darker and more difficult discolorations canbetreatedwithhomebleaching productscontaining10percentcar- bamideperoxide,however,thiswill extend the duration of the treat- mentto8to10weeks.Treatingtetra- cycline stained teeth (Type 3 and 4) can even last from 3 to 12 months. A basic bleaching case with no re- quirement of restorative dentistry will take 4 to 6 weeks to achieve a whitening effect. There are no age restrictions for teeth whitening. (Kelleher et al. 2011) However, older teeth have thinner enamel, thicker dentine and are more heavily compacted with secondary dentine. Therefore, they will take longer to whiten. Younger teeth will whiten faster as their structural anatomy is characterised by open odontoblas- tic processes when the enamel is young. Despite the fact that there are larger pulp canals and pulp chambers, young patients who un- dertake whitening do not show moresensitivitythanolderpatients (Greenwall 2009). Overthelast25years,ithasbeen possible to whiten teeth beyond the normal original Vita classic shades. There are some patients that have developed a syndrome where they continually seek whiter teeth. This phenomenon is associated with body dysmorphophobia and low self-esteem. It has been described as bleachorexia (Kelleher 2014) but actually it should be referred to as ableachoholic.Thesepatientsusing tactics similar to those that are never satisfied with their dentures. Itisessentialthatthedentistknows howtodetectsignsofthissyndrome andisnotbeseducedintoundertak- ing unnecessary whitening treat- ment for only the patient’s sake of getting attention. Normally, these patients can be detected early as their teeth are whiter than the sclera of their eyes. It is essential that when whitening treatment is completed the patient is told that no further whitening is necessary at that point. Each whitening cycle will require the dentist to reassess the patient in order to decide whether additional whitening is necessary. New shade guides have been de- veloped to match the new shades of white and porcelain and composite shades have been introduced onto the market to be able to restore theseteethtothenewwhitershade. Therearenownewbleachedshades ofcompositerestorativematerialso that after whitening, restorations canbeplacedatthenewlightenand whitershadessothatthecomposite filling materials match the new shade of the teeth. Conclusion Professional tooth whitening products are safe, effective and pre- dictable. Side effects such as sen- sitivity can be managed well since the latest generations of whitening products contains extra soothers such as potassium nitrate, fluoride andamorphouscalciumphosphate. Patients have benefitted from treat- ments that are being able to im- prove their smiles in a natural and non-invasive way. It can expected that the amount of professional toothwhiteningmaterialsavailable for dentists will continue to in- crease. In addition, there are many newinnovativewhiteningproducts which are being brought onto the market for patients to continue to enjoy a whiter, brighter smile. Dr Linda Greenwall will be speaking at the IDEM Singapore 2016 conference to be held from 8–10 April, 2016. Do join us at IDEM Singapore 2016, gateway to the Asia Pacific’s dental market, with a massive 18,000 sqm of ex- hibitions space, over 550 interna- tional exhibitors and many of the world’s experts in dental practice, education and research! To find out more information about what Dr Greenwall will be speaking on, please visit her page. Also, you may visit IDEM’s social media sites on Facebook,LinkedInandYouTube.7 4b 4a 5 Fig. 4a: Teeth before whitening. Multiple recession areas of the gingivae are visible. This patient was treated with a whitening tray containing asoothinggelforaweekpriortoundertakingwhiteningtoensurethatthepatientwasfreeofsensitivity.—5 Fig.4b:Thispatientwastreatedwith 10percentcarbamideperoxideandtwosessionsofmicroabrasion(Opalustrepaste,Ultradent)toremovetheremainingwhitemarksontheteeth. 5 Fig. 5: A selection of whitening materials containing carbamide peroxide for night time use in a bleaching tray. TDI0816_06-07_Greenwall 05.04.16 13:47 Seite 7 TDI0816_06-07_Greenwall 05.04.1613:47 Seite 7