03AS9284
Please Share This Valuable Information With All Doctors, Hygienists, and Assistants In The Office
Introduction
Never before in the history of dentistry
has a dental procedure received the
amount of mass media promotion as
vital tooth whitening. Improved
esthetic treatment options have given
the dental professional the ability to
provide esthetic choices while
preserving sound tooth structure. Vital
tooth whitening is one of the esthetic
choices the dental professional can offer
to patients. Whitening is simple, non-
invasive and inexpensive. Dr. James
Dunn, whitening expert at Loma Linda
University School of Dentistry in
California, has commented that
whitening is perhaps the only
procedure in dentistry that is
considered a pleasurable experience by
patients. Dr. Dunn goes on to say that
whitening is associated with the
1 Figure 1
perception of youth, health and beauty.
Whitening Options
The general public is confused about
the different whitening options that are
available. The current options include
over-the-counter, dentist prescribed
take-home, and in-office whitening
systems. As dental professionals we
have the opportunity and the duty to
educate our patients about these
whitening
Distributed by:
options. Over the counter (OTC)
products contain various
concentrations of carbamide peroxide
or hydrogen peroxide. These products
have been shown to cause gingival
irritation or damage due to poorly
contoured trays. The active ingredients
in OTC products are acetic or citric
acids that can cause loss of tooth
2
structure after repeated use.
Figure 2
recommended treatment time, isolation,
3
and suggested operator. For example,
Illumine® (figure 1), 30 % hydrogen
peroxide, is a 30-minute in-office
system that does not require light or
laser activation. Due to Illumine’s bio-
adhesive properties it does not require
gingival isolation. Illumine is generally
used as a boost.
In office systems such as Illumine™
(DENTSPLY Professional, York, PA)
and Perfection White (Premier Dental
Products Company, Plymouth Meeting,
PA) are 30 to 35% hydrogen peroxide.
In the April 2002 Dental Products
Report on in-office bleaching systems
Figure 3
Dr. Freedman recommends utilizing the
following criteria. For selecting an A home-whitening adjunct such as
in-office product: light activation, light NUPRO White Gold™(figure 2) or
sources, bleaching chemistry, Perfecta® Bravo™ (figure 3) is
desensitizers, home-bleaching adjunct, recommended.
Sullivan-Schein Dental is an ADA
CERP recognized provider.
 Dentist prescribed take-home systems
are 4.5 to 9% hydrogen peroxide or
10 to 22% carbamide or urea peroxide.
Urea provides an acid pH that
stabilizes the product during storage
and extends the shelf life. Upon
activation in the oral cavity, the urea
by-products elevate the pH to an
alkaline level that begins the whitening
process within five minutes and keeps
4
the product active for several hours.
Take-home systems are professionally
monitored while offering the patient
the convenience of using the product at
home. The fee for take-home systems is
usually reasonable. These systems are
safe and effective and have clinically
proven results. When evaluating a take-
home product for effectiveness the
following criteria can be helpful: a
continuous release whitening agent
with a neutral or palatable taste, high
viscosity, and varied concentrations of
carbamide peroxide.
TABLE 1
PATIENT CONSIDERATIONS
• Extremely large pulp chambers
• Pulpal resorption
• Existing hypersensitivity
• Severe loss of enamel
• Immature enamel
• Extensive restorations
• Peroxide allergy
• Latex allergy
• Pregnant or lactating
• Behavioral habits
• Lack of compliance
• Patient expectations
Patient Selection and
Treatment Considerations
Evaluation of the cause and extent of
the stain is important for successful
whitening. Causes of discoloration can
be extrinsic, intrinsic or age related.
2
Patients with yellow, orange or light
musky brown teeth will usually achieve
the best whitening results. Patients in
the gray or bluish gray ranges will be
less successful even after prolonged
treatment. A behavioral habit such as
smoking, coffee and tea drinking, and
red wine consumption will influence
results and must be considered. Other
patient considerations are listed in
table 1. Patients who are not likely to be
compliant or patients whose
expectations are unrealistic or
unachievable may not be the best
whitening candidates. For example, the
color of the teeth should match the
color of the white area (sclera) of the
eyes. Teeth that are made whiter than
one’s eyes can look unnatural.
Initial Consultation
During the initial consultation, review
the medical and dental history and
conduct a comprehensive oral
examination. Discuss the whitening
system with the patient including
expectations and considerations.
Review any potential problems or side
effects. For example, it can take one to
three months to remove nicotine stains.
Also, tetracycline stains tightly bond to
dentin. The cervical third is the hardest
to whiten because it contains the largest
amount of dentin. Inform the patient
that any existing tooth colored
restorations may not match the lighter
shade of teeth after the whitening
treatment and will most likely need to
be replaced. Wait one to two weeks
post treatment before replacing any
esthetic restorations due to residual
oxygen remaining in the tooth which
will cause a transient reduction in bond
5
strength. Make the patient aware that
uneven white spots will blend over
time. Once a treatment plan is
formulated the patient should be
scheduled for oral hygiene instruction,
prophylaxis using the Cavitron Prophy
Jet™ air polishing system or NUPRO™
prophy paste, and a topical fluoride
treatment with NUPRO™ fluoride gel or
All Solutions® rinse. An alginate
impression of the arch to be lightened
should be taken. DENTSPLY
Professional recommends whitening
one arch at a time to minimize occlusal
discomfort as well as to enable the
patient to see shade change. The patient
must then be scheduled for tray
delivery.
Figure 4
Tray Fabrication
The alginate impression is disinfected
and thoroughly rinsed. The impression
is poured in laboratory stone. Allow the
stone to dry to an effective hardness.
Trim the stone cast so that the base is
parallel to the occlusal plane of the
posterior teeth and extends two to four
millimeters past the gingival border. In
the case of a maxillary model, a drilled
hole through the pallet will ensure a
better fit on tooth surfaces when
creating a tray. If creating reservoirs,
apply an appropriate block-out gel such
as Triad® Gel (DENTSPLY Caulk, York,
PA) (figure 4). The gel will serve as a
space that creates reservoirs in the
whitening tray. Apply approximately a
1 to 1.5-mm thickness of the gel to the
facial surfaces of the teeth to be
whitened. When using the Triad® Gel a
disposable dispensing tip that attaches
to the end of the syringe for easy
application is provided. Stay
approximately 1 mm from the gingival
margins and incisal/occlusal surfaces,
avoid apply gel in interproximal areas.
Cure the gel by applying a handheld
curing light for 30 to 60 seconds per
tooth, or place the model in the Triad®

Figure 5
Visible Light Cure (VLC) unit
(DENTSPLY Caulk, York, PA) for two
minutes (figure 5). Wipe the cured gel
surfaces with alcohol-moistened gauze
or cotton strip to remove excess
material or oxygen-inhibited residue.
Some manufacturers do not
recommend the use of reservoirs.
Figure 6
Place the tray material (pebble finish
toward the model) on a heat/vacuum
tray-forming machine. Soften the
whitening sheet until it sags 1 to 2
inches. Engage the vacuum. Slowly
lower the heated whitening tray onto
the stone model. Allow ample time
under the vacuum for optimal retention
and definition. After the tray has
cooled, remove it from the stone model.
Using scissors, trim the tray
approximately 2 to 3 mm beyond the
teeth (figure 6). Trim and refine the
remaining portion with precision
scissors, scalloping around the
interdental areas. Or trim the tray
directly on the model using a soft tray
trimmer such as Tray Magic™ (Premier
Dental Products Company, Plymouth
Meeting, PA) (figure 7). Trim the tray
approximately .5 to 1 mm short of the
gingival margin. Lightly flame-polish
the tray edges. Check for fit of tray on
stone model. If the tray does not fit
properly, use a flame torch to reapply
and recontour the application tray
where necessary. Wash and disinfect the
whitening tray. Dry thoroughly and
place in a storage case for delivery.
Figure 7
Tray Delivery and
Whitening Instructions
At the tray delivery appointment, the
baseline shade will be documented.
Also pretreatment photographs with
and without the shade guide can be
taken. The tray is tried in for proper fit
and comfort. The whitening procedure
is reviewed with the patient. The
American Dental Association (ADA)
recommends the use of a value oriented
shade system that is sequenced by
brightness. Factors influencing the
shade determination are ambient light
and the clinician’s vision. The ambient
light should be consistent, neutral,
reproducible and unbiased. Gender,
age, genetics and distance can all affect
the clinician’s vision. In general, the
youngest female member of the dental
team should be involved in the shade
determination.
Patient education should include
loading and seating the tray. Review
with the patient the teeth to be
whitened. Demonstrate placing a small
bead of the whitening agent along the
front base of the tray and emphasize
the importance of utilizing the proper
dose of the whitening agent.
The whitening tray should be seated
from side to side and excess gel wiped
away. Instruct the patient on the use of
the take-home shade guide. The patient
will use the guide to document and
date shade changes.
Patients need to be aware of the
saturation point. The saturation point is
the point at which only hydrophilic
colorless structures or stainless
molecules exist. Optimal bleaching
achieves whitening, over-bleaching
degrades tooth enamel without further
whitening.6
Post-daily treatment instructions
include removing the tray, rinsing, and
brushing and flossing to remove any
residual whitening agent remaining on
tooth surfaces. A separate toothbrush
should be used to clean the tray, and
then the tray should be stored in a case
with mouthwash or water. Instruct the
patient to call with any questions or
concerns, and re-schedule for a
follow-up.
Whitening Success and
Compliance
The number one reason for whitening
success is compliance. Comprehensive
and understandable patient education
will ensure patient acceptance and is
critical to whitening success. Despite
claims that some whitening products
do not cause sensitivity, double blind
clinical studies have shown that
sensitivity occurs in 55 to 75% of
treatment.7 Treatment of tooth
sensitivity can be active or passive.
Passive treatment for sensitivity
involves reducing treatment time or
frequency of treatment, and
interruption or cessation of the
whitening treatment. Shorter wear time,
such as 30 minutes once-a-day, as is
recommended for Perfecta® Bravo™
(Premier Dental Products Co.) can help
improve patient compliance.
3
 Sensitivity can be treated actively through pretreatment with neutral sodium
TABLE 2, MARKETING IDEAS
fluoride, application of an in-office fluoride treatment followed by a home-
applied fluoride, or use of other therapeutic agents. Haywood, et al recommend Develop Gift Certificates for Life
Occasions
tray delivery of a 5% potassium nitrate – 1000 ppm fluoride gel.8
A comfortable, properly fitting tray, a palatable whitening agent with proper Compile a Photo Album of “Successes”
viscosity, and an appropriate delivery system are also critical to whitening Use Statement Stuffers
success. Whiten Staff Members Teeth
One Arch at a Time
Post-Visit and Marketing Ideas
Intraoral Camera
Document the final shade, and take photographs with and without a shade
guide. Obtain a testimony from the patient for marketing purposes. Review Value Arranged Shade Operatory Display
maintenance issues with the patient. Take-home treatment results typically last Posters/Brochures
two to three years, while in-office treatments last four to five years.9 Telephone “On Hold” Message
The goal of incorporating whitening into your practice should involve educating Target Mailing
the patient about whitening. Marketing ideas for incorporating whitening into Website
the practice are listed in table 2.

BIBLIOGRAPHY
1. Dunn, JR. Whitening Symposium. Tufts University: Oct 2000. 8. Haywood, VB, Leonard, RH, Nelson, CF, and Brunson, WD. Effectiveness,
2. Dunn, JR. Dentist-prescribed home bleaching: current status. Compendium side effects, and long-term status of nightguard vital bleaching. J Am Dent
19(8): 760-764, 1998. Asso. 1994 Sep; 125(9): 1219-1226.

3. Freedman, G. In-office bleaching systems. Dental Products Report: April
2002.
4. Leonard, RH Jr, Haywood, VB, and Bentley, CD. Quintessence Int. 1994 Aug;
25(8): 547-550.
5. Goldstein, RE, Garber, DA. Complete Dental Bleaching 1995: 96.
6. Albers, H. ADEPT Report 1991; 2(1): 1-24.
7. Haywood, VB, Caughman, WF, Frazier, KB, and Meyers, ML. Tray delivery
of potassium nitrate-fluoride to reduce bleaching sensitivity. Compendium
21(28): S10-S17, 2000.
9. Freedman, G. Yankee Dental Congress 1999.
Sandra Marcil, RDH, MS, is the Southeast Clinical Educator for DENTSPLY
International, Professional Division, York, PA. Ms. Marcil presents continuing
education courses and academic lectures nationally on topics related to
ultrasonic therapy, air polishing, tooth whitening and sealants. Ms. Marcil
recently received her Masters of Science degree through a distance learning
program at the Florida Gulf Coast University. She may be reached at:
smarcil@dentsply.com or 727-298-8311.

COURSE SPONSOR IMPORTANT INFORMATION

Sullivan-Schein Dental is course sponsor. Sullivan-Schein Dental's ADA CERP The opinions of efficacy or perceived value of any products or companies
recognition runs from November 2001 to December 2004. mentioned in this course and expressed herein are those of the author(s) and do
not necessarily reflect those of Sullivan-Schein Dental. Completing a single
COURSE CREDITS continuing education course does not provide enough information to make the
participant an expert in the field related to the course topic. It is a combination of
All participants scoring at least 80% on the examination will receive a certificate
many educational courses and clinical experiences that allows the participant to
verifying 3 CEUs. The formal continuing education program of this sponsor is
develop the skills, broad-based knowledge and expertise related to the subject
accepted by the AGD for Fellowship/Mastership credit. The current term of
matter.
acceptance extends from December 2001 to December 2004. Participants are
urged to contact their state dental boards for continuing education requirements.
COURSE FEE/REFUND POLICY
The cost for this course is $55.00. Any participant who is not 100% satisfied
PARTICIPANT FEEDBACK
with this course can request a full refund by contacting: Sullivan-Schein Dental,
If any participant wishes to communicate with the author of this course, please Attn: CEHP, 26600 Haggerty Rd., Farmington Hills, MI 48331.
fax questions to: Sullivan-Schein Dental by fax to 1-800-781-6337. Be sure to
provide us with the following information: name, address, e-mail address,
telephone number, and course completed. COURSE EVALUATION
We encourage participant feedback pertaining to all courses. Please be sure to
complete the attached survey included with the answer sheet.
RECORD KEEPING
Sullivan-Schein Dental maintains records of your successful completion of
any CE Seminars. Please contact our offices at Sullivan-Schein Dental, Attn: CEHP,
26600 Haggerty Rd., Farmington Hills, MI 48331, by mailing a note requesting a
copy of your continuing education credits report. This report, which will list all
credits earned to date, will be generated and mailed to you within five business
days of receipt.

Distributed by:

Sullivan-Schein Dental is an ADA

CERP recognized provider.

4
 ©2002 Premier Dental Products Co.

NEW Perfecta Bravó™ from Premier® ®

A new day in take-home tooth whitening

Shorter wear time – 30 minutes, once a day
Proven faster results1 for improved compliance
Patented water-based 9% hydrogen peroxide gel
84% less wear time – for two-week treatment
Superior whitening without sensitivity

Take-home gel for $21.42 per patient – ask your Sullivan-Schein Sales Consultant!
Visit DenTrek.com – view brief tutorial.

Value Pak (378-9671-VB) . . . . . . . . . . . . . .$128.49 Patient Pak (378-3479-VB) . . . . .$36.99 8 @ $34.99

Value Pak contains: 24 – 3cc syringes (enough whitening Patient Pak contains: 4 – 3cc syringes with dispensing tips,
material for six patients), 24 dispensing tips, patient patient instructions with shade guide, doctor instructions,
instructions with shade guide PLUS six FREE cosmetic cosmetic patient travel pouch with mirror, EVA material and
patient pouches. You add trays and tray cases. tray case.

1. Clinical Evaluation of the Bleaching Efficacy of Two Different Concentrations, Sheila H. Koh, D.D.S., F.A.G.D.UTHSC-Dental Branch; Esthetic Professionals-Dental Materials and Technology Update, July 2002.
5
 Continuing Education Test Questions
Answer Sheet on Back Cover

1. Each of the following whitening options is professionally 9. Which of the following is required for proper fabrication of
monitored except: whitening trays?
a. in office a. pour model in stone
b. over the counter b. trim the tray .5 – 1 mm from the gingival margin
c. dentist prescribed c. pour model in plaster
d. walking bleaching d. both a & b

2. In office whitening systems are generally 30- 35% hydrogen 10. The ADA recommended value oriented shade system is
peroxide. Dentist prescribed take-home systems can range sequenced by:
from 4.9 to 22% carbamide peroxide. a. brightness
a. Both statements are true. b. color
b. Both statements are false. c. eruption patterns
c. The first statement is true; the second is false. d. age
d. The first statement is false; the second is true.
11. Which of the following factors will influence the shade
3. An acid pH extends the shelf life of the whitening agent. An determination?
alkaline pH begins the whitening process within five minutes a. ambient light
and allows the process to continue for several hours. b. clinician’s vision
a. Both statements are true. c. patient’s age
b. Both statements are false. d. both a & b
c. The first statement is true; the second is false.
d. The first statement is false; the second is true. 12. When selecting patients for whitening options which of the
following should be considered?
4. Patients with yellow, orange or light musky brown teeth will a. behavioral habits
usually have the best whitening results. b. patient expectations
a. True c. extent of stain
b. False d. all of the above

5. Evaluation of the cause and extent of the stain is not 13. Sensitivity occurs in 55 – 75% of whitening cases.
important for successful whitening. a. True
a. True b. False
b. False
14. Sensitivity can be actively treated through pretreatment
6. Which of the following criteria are helpful in evaluating a with neutral sodium fluoride.
take-home whitening system? a. True
a. high viscosity b. False
b. continuous release
c. neutral or palatable taste 15. Take-home treatment results typically last two to three
d. all are helpful years. In-office treatment results last four to five years.
a. Both statements are true.
7. Wait one to two weeks post whitening treatment before b. Both statements are false.
replacing any esthetic restorations. c. The first statement is true; the second is false.
a. True d. The first statement is false; the second is true.
b. False

8. Patient compliance is not critical to whitening success.

a. True
b. False

6
 Two years after her whitening,
Beth’s friends and family still look at her differently
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Median shade change maintained
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10
Number of Shade Changes from Baseline†
8
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6
4
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End of
Active Bleaching
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Vita shade units on 16-tab value-oriented shade guide.
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*According to American Dental Association guidelines, a bleaching material is judged to be efficacious
if its use results in at least 2 shade changes according to a value-oriented Vita shade guide.1
Reference: 1. Swift EJ, May KN, Wilder AD, Heymann HO, Bayne SC. Two-year clinical evaluation
12 @ 9.99 of tooth whitening using an at-home bleaching system. J Esthet Dent. 1999;11(1):36-42.
For ordering information, contact your local DENTSPLY Professional
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7
Vital Tooth Whitening – The Gold Experience
Sandra
Sandra Marcil,
Marcil, RDH,
RDH, MS
MS

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3 CE
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