Treatment Considerations for Dentists and Their Patients

Over the past two decades, tooth whitening or bleaching has become one of the most popular esthetic dental treatments  The tooth whitening market has evolved into four categories: professionally applied (in the dental office); dentist-prescribed/dispensed (patient home-use); consumer-purchased/over-the-counter (OTC) (applied by patients); and other non-dental options. Additionally, dentist-dispensed bleaching materials are sometimes used at home after dental office bleaching to maintain or improve whitening results.  Consumer whitening products available today for home use include gels, rinses, chewing gums, toothpastes, paint-on films and strips.

The latest tooth whitening trend is the availability of whitening treatments or kits in non-dental retail settings, such as mall kiosks, salons, spas and, more recently, aboard passenger cruise ships. Non-dental whitening venues have come under scrutiny in several states and jurisdictions, resulting in actions to reserve the delivery of this service to dentists or appropriately supervised allied dental personnel.
Current tooth bleaching materials are based primarily on either hydrogen peroxide or carbamide peroxide. Both may change the inherent color of the teeth, but have different considerations for safety and efficacy. In general, most in-office and dentist-prescribed, at-home bleaching techniques have been shown to be effective, although results may vary depending on such factors as type of stain, age of patient, concentration of the active agent, and treatment time and frequency. However, concerns have remained about the long-term safety of unsupervised bleaching procedures, due to abuse and possible undiagnosed or underlying oral health problems.  Although published studies tend to suggest that bleaching is a relatively safe procedure, investigators continue to report adverse effects on hard tissue, soft tissue, and restorative materials.(Note: this paper uses the terms "whitening" and “bleaching," interchangeably). Since the 1800s, the initial focus of dentists in this area was on in-office bleaching of non-vital teeth that had discolored as a result of trauma to the tooth or from endodontic treatment. By the late 1980s, the field of tooth whitening dramatically changed with the development of dentist-prescribed, home-applied bleaching (tray bleaching) and other products and techniques for vital tooth bleaching that could be applied both in the dental office and at home. 1-3 The rate of adverse events from use or abuse of home-use OTC products is also unclear because consumers rarely report problems through the U.S. Food and Drug Administration (FDA) Medwatch system. Based on these factors, the American Dental Association (ADA) has advised patients to consult with their dentists to determine the most appropriate whitening treatment, particularly for those  with tooth sensitivity, dental restorations, extremely dark stains, and single dark teeth.
The purpose of this report is to outline treatment considerations for dentists and their patients prior to tooth whitening/bleaching procedures so that the potential for adverse effects can be minimized. This report does not address agents used for non-vital intracoronal bleaching procedures. 4 Additionally, a patient’s tooth discoloration may be caused by a specific problem that either will not be affected by whitening agents and/or may be a sign of a disease or condition that requires dental therapy.