Ortho Tribune Middle East & Africa No. 3, 2019

N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me May-June | No. 3, Vol. 9 Tooth whitening and orthodontics: The icing on the cake By Dr Yassine Harichane, Canada Tooth whitening is a therapeutic procedure that provides the ﬁ nal touch to orthodontic treatment. The objectives in orthodontics are both functional — restore masticatory function, swallowing, breathing and phonation—and aesthetic—balance and harmonise the face, and im- prove the smile. To achieve the last goal, various criteria are taken into account: tooth alignment, shade and shape, and even the shape of the lips. All these parameters are important; however, the most visible aspect of the smile is the dental shade. One can restore function, correct an oc- clusal dysfunction, close a diastema or even inject dermal ﬁ llers, but if the teeth are left yellowish, the smile re- mains unattractive. Tooth whitening is a therapeutic solution that restores the natural lustre of the teeth by re- moving organic stains, which means it is not tooth bleaching. For the or- thodontist, there are only advantag- es. It is easy to perform, non-invasive, requires no anaesthesia and produc- es no irreversible destruction of the tooth. This procedure is rewarding for the dental team, since the dental assistant can be involved in all steps of the process. It is suitable for the majority of patients. Tooth whiten- ing is a cost-effective technique that requires little material and time, and is efﬁ cient if the practitioner is rigor- ous. Finally, the main concern for pa- tients, it is painless. How does it work? The enamel shade can change be- cause of tobacco stains, food or trauma, for instance. The protocol involves the application of a tooth whitening product, such as hydro- gen peroxide, carbamide peroxide or sodium perborate. The last one must be avoided, since it is classiﬁ ed as repro-toxic. The ﬁ rst two are efﬁ cient and safe. The difference between them lies in the fact that hydrogen peroxide is the active ingredient and carbamide peroxide is a derivative that degrades into hydrogen perox- ide. This release is progressive and slow. This process is suitable when the practitioner desires a soft and progressive effect. Regarding dosage, the percentage provided by the man- ufacturer reﬂ ects the concentration: 1% of hydrogen peroxide is equiva- lent to 3% of carbamide peroxide. In Europe, the maximum limit for vital teeth is 6% hydrogen peroxide or 18% carbamide peroxide. What are the indications? There are two main indications: in- trinsic post-eruptive stains and ex- trinsic stains. Intrinsic post-eruptive stains concern mostly clinical cases involving pulp necrosis (trauma, endodontic treatment, endodon- tic calciﬁ cation). Among extrinsic stains, there are tobacco stains, discolouration due to ageing and physiological stains. It is in the last category to which most post-ortho- dontic treatment applies. Indeed, tooth whitening will allow beauti- ful ﬁ nishing by complimenting the orthodontic result. The patient will notice the difference—the teeth are well-aligned and whiter—and forget that the orthodontic process took so much time, as the tooth whiten- ing needs just a few days. The treat- ment is of beneﬁ t to the practice too, since the orthodontist not only restores the function, but improves the aesthetic outcome painlessly too. How to perform tooth whitening The different techniques will be demonstrated through clinical cases. In the ﬁ rst case, the patient was being treated with a lingual appliance (Fig. 1) and wished to whiten her teeth. In- ofﬁ ce tooth whitening was deemed the most suitable. The soft tissue— gingivae, tongue and lips—must be protected (Fig. 2). The product is applied to the vestibular aspects of the teeth (Fig. 3) and renewed every 15–20 minutes. A good result can be obtained (Fig. 4) with a gentle and ef- ﬁ cient product containing 6% hydro- gen peroxide (Opalescence Ofﬁ ce, Ultradent Products; Fig. 5). Hydrogen peroxide was chosen because, being the active ingredient, its efﬁ cacy is immediate. A 6% concentration is the limit, but it is strong enough to observe a difference and low enough to avoid temporary thermic hyper- sensitivity. A take-home whitening process entails the use of trays loaded with tooth whitening gel. After an ortho- dontic treatment, two options are available. An impression of both arches is taken, then stone models are prepared. A soft tray sheet is ther- moformed, which allows the making of custom whitening trays (Fig. 6). At the second appointment, the patient receives the trays and the product, together with the user instructions for one or two weeks on the basis of daily use for 60–120 minutes (Fig. 7). For this application, carbamide peroxide of 10% or 16% is chosen (Opalescence PF, Ultradent Products; Fig. 8). The choice of carbamide per- oxide is suitable for at-home applica- tion, since the gel releases hydrogen peroxide progressively. The choice of concentration depends on the clinical case. A young patient or a patient with already treated thermic hypersensitivity should use 10% car- bamide peroxide. Any other patient or a former smoker should use 16% carbamide peroxide. For at-home application, if the practitioner does not wish to prepare trays in-ofﬁ ce or Fig. 1: Patient undergoing lingual orthodontic treatment. Fig. 2: Soft-tissue protection during the in-ofﬁ ce tooth whitening procedure. Fig. 3: Application of tooth whitening gel to the vestibular aspects of the teeth. Fig. 4: Before and after in-ofﬁ ce tooth whitening on a patient wearing a lingual appliance. Fig. 5: Opalescence Ofﬁ ce kit for in-ofﬁ ce whitening. Fig. 6: Custom trays Fig. 7: Clinical case before and after at-home tooth whitening using custom trays. Fig. 8: Opalescence PF kit for at-home whitening. through the laboratory, an already prepared kit containing ready-to- wear trays can be used (Opalescence Go, Ultradent Products; Fig. 9). In this case, at the ﬁ rst appointment, the patient receives a kit containing a tray pre-ﬁ lled with tooth whitening product. Once at home, over ten days approximatively, the patient applies the tray into the mouth and leaves the gel to work for 60–90 min- utes (Figs. 10 & 11). It is a huge time-saving approach for the patient and the orthodontist, with an uncompro- mised result. ÿPage D2

D2 ◊Page D1 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 3/2019 During the whitening, the patient should not smoke or consume stain- ing drinks like coffee and tea to avoid any re-colouration of the teeth. The best solution is to perform ﬂ uoride application after the treatment. The ﬂ uoride kit (Biﬂ uorid 10, VOCO; Fig. 16) contains single doses to apply to the vestibular aspects of the teeth. This ﬂ uoride varnish will protect the tooth surface against staining in or- der to maintain a long-term result. What about the law? In Europe, hydrogen peroxide is lim- ited to 6% (18% carbamide peroxide) for vital teeth. This concentration is really enough for a tooth whiten- ing, but not sufﬁ cient if the patient comes to the ofﬁ ce expecting a Hol- lywood smile. Since hydrogen and carbamide peroxide are efﬁ cient, there is no reason to use sodium perborate, but it is not prohibited. Fi- nally, the dental assistant is allowed to be involved in the process. He or she can take the photographs, meas- ure the dental shade before and after the treatment, prepare the trays and even explain the instructions of use. All of this is simple and accessible. The orthodontist should refer to national regulations to determine whether the dental assistant can take impressions or apply the gel to the teeth. However, diagnosis and re- sponsibility remain the duties of the practitioner. Conclusion Tooth whitening is a procedure that complements orthodontic ﬁ nishing. It is a ﬁ nal touch that makes a visible difference. The technique is simple and does not require long and fastid- ious training, only strict adherence to the protocol. The practitioner’s rigour is enough to understand the protocol. This aesthetic dentistry tool adds value to the orthodontic of- ﬁ ce and to the dental team involved in the process, from the front desk to the chair, not to mention that it signiﬁ cantly improves the before and after photographs. Finally, eve- rybody, the patient and the team, is satisﬁ ed at the end of the treatment. Conﬂ ict of interest and acknowledgements The author has no disclosures to make. The author would like to thank Dr Shiraz Khan for the proof- reading and friendly support. Dr Yassine Harichane graduated from Paris Descartes Univer- sity in France and completed his MSc and PhD on dental pulp stem cells. He main- tains a private practice in Canada and can be contactedat: yassine.harichane@gmail.com AD Fig. 9: Opalescence Go kit for at-home whitening. Fig. 10: Clinical case before and after tooth whitening using ready-to-wear trays. Fig. 11: Pre-ﬁ lled trays on the teeth. Fig. 12: Proﬂ uorid Varnish for dental hypersensitivity treatment. Fig. 13: Remin Pro for home use. Fig. 14: Remin Pro Forte for home use. Fig. 15: Stone model with resin on the vestibular aspects of the teeth for tray reservoirs. Fig. 16: Biﬂ uorid 10 for in-ofﬁ ce ﬂ uoride application. Cost of materials and treatment fee For in-ofﬁ ce application, an Opal- escence Ofﬁ ce kit costs approxima- tively €90. Generally, the kit con- tains two syringes, enough for two appointments with the same patient or two different patients. For at- home application, if the ofﬁ ce owns a thermoforming machine, the den- tal assistant prepares the trays, and two thermoforming sheets cost €2. Otherwise, a dental technician usu- ally charges €50 to produce a pair of custom trays. The Opalescence PF kit with carbamide peroxide costs about €60 for the 10% or 16% con- centration. If the orthodontist does not wish to spend time and money on custom trays, the ready-to-use kit should be used. It costs €70 for the trays already loaded with tooth whit- ening gel. In-ofﬁ ce application requires one hour. The practitioner does not need to be with the patient throughout the entire procedure, but applies the gel and leaves it to complete its cycle. For custom trays, a ﬁ rst appointment is necessary for the impressions and another to deliver the trays and the product, taking altogether less than 15 minutes. Otherwise, the pre-ﬁ lled trays are delivered to the patient and the dental assistant explains the process in a short appointment. In my experience, having custom trays with good ﬁ t will signiﬁ cantly reduce any saliva ingress and always pro- vide optimal results. The fee depends on the ﬁ nancial strategy of the ofﬁ ce. The treatment may be free, in order to offer a gift after a long and/or expensive ortho- dontic procedure, or to compensate for an imperfect ﬁ nal result. If this is a gift, the patient feels privileged. Otherwise, the fees are calculated according to the hourly cost of the ofﬁ ce, based on the time spent on the process as estimated by the spe- cialist. A ﬁ nal possibility is for the practice owner to determine the fee based on that charged by competing practices. The mean cost is €700 for in-ofﬁ ce application, €400 for at- home application with custom trays and €200 for the Opalescence Go kit. Tips and tricks Previously, it was noted that ther- mic hypersensitivity can occur. It is better to prevent this, and to this end, the specialist has a great deal of choice. Among the plethora of prod- ucts on the market, we have found Proﬂ uorid Varnish (VOCO; Fig. 12) to offer particular stability. This var- nish, which is applied to the tooth surface, has desensitising properties. Its use is entirely suitable for tooth whitening. We also recommend sending the patient home with a prophylaxis kit (Remin Pro or Remin Pro Forte, VOCO; Figs. 13 & 14). Another tip is to use orthodontic aligners to perform the at-home whitening. The only disadvantage is that the whitening product will be squeezed between the tray and the teeth and can ﬂ ow to the gingivae when positioning the tray in the mouth. That is the reason to prefer custom trays. The limits follow the gingival margin in order to avoid po- tential excess. Moreover, we strongly recommend reading the manufac- turer’s instructions and preparing a reservoir in the tray according to the manufacturer’s instructions. To this end, one need only add some resin to the vestibular aspects of the teeth on the stone model (Fig. 15). The advantage is double, since the reser- voirs will guide the patient to put the exact quantity of gel in the correct place with no excess. dereviled swen-e raluger – to your inbox gnidrocca tnetnoc dezilaudividni – to your specialty & region stnempoleved yrtsudni tsetal – – event specials sweivretni evisulcxe – with key opinion leaders – product information – clinical cases – job adverts www.dental-tribune.me

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