Enlightened and whitened: An overview on bleaching and patient assessment

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Enlightened and whitened: An overview on bleaching and patient assessment

Julie Seager, RDH, BS
Julie Seager, RDH, BS

Julie Seager, RDH, BS

Tue. 22 June 2010


A patient who is happy with his or her smile will ultimately be a more compliant patient. One of the easiest and most significant methods to achieving an esthetically pleasing smile is to bleach the teeth. There are reports of teeth whitening dating back more than 1,000 years, and today people are now more than ever wanting this cosmetic procedure.

Surveys show that more than 80 per cent of people want whiter teeth, but only 15 per cent have ever used a bleaching product. That leaves 65 per cent of patients eligible to be approached about bleaching.

Proper patient evaluation and a good approach can bring a large increase in case acceptance for bleaching.

Thoughtful consideration of the patient’s age, habits and current restorations should be used when determining which bleaching product should be matched to the patient.

Dental offices should have several product options available as not every patient has the same bleaching needs.

Bleaching options

With so many bleaching products on the market, it is easy to be confused about what is safe and effective to recommend to patients. Many dental offices already provide the service of take-home bleaching trays to patients.

The trend of in-office bleaching is gaining popularity as techniques and equipment become more cost effective and easy to administer.

The two types of take-home bleaching gels available to patients are carbamide peroxide and hydrogen peroxide. Carbamide peroxide gel is a slow-release gel with about one-third the strength of hydrogen peroxide.

It usually works with a two- to four-hour release time, making it ideal for patients who want to wear trays while they sleep.

Hydrogen peroxide gels are faster acting, releasing the peroxide between 30 and 60 minutes, and will usually come in concentrations from 5 to 10 per cent. Some manufacturers also now offer 35 to 40 per cent carbamide peroxide gels for home use, which only require a 25- to 30- minute application.

This gel concentration is perfect for patients who do not have much time to whiten, want fast results and are not prone to sensitivity.

In-office bleaching gels usually are 25 to 30 per cent hydrogen peroxide and need to be used only with supervision of a professional to ensure the gel is properly applied and will not harm the soft tissues.


Several dental manufacturers recognize that sensitivity can limit a patient’s whitening potential, and now there are several bleaching gels that contain fluoride, amorphous calcium phosphate (ACP) or a combination of the two.

Patients with dentinal hypersensitivity can often pose a big challenge to teeth bleaching, but this can be easily remedied with proper pre-treatment protocol.

For 10 days to two weeks prior to beginning the bleaching process, a sodium fluoride or product containing ACP should be used once or twice a day and then again as needed during the course of treatment.

If performing chairside bleaching, care should be taken to cover exposed root surfaces and worn incisal edges with a protective dam or bonding agent.

Special circumstances

Patients receiving cosmetic restorations after bleaching will benefit from waiting two weeks for the oxygen and hydration in the tooth to return to normal levels. At this time, the final shade will have stabilized and the teeth will achieve the strongest bonding strength.

Patients with white-spot lesions, or fluorosis, will want to bleach the teeth to an ideal shade and then follow up with an air-abrasion appointment to smooth and even out the appearance and texture of the enamel.

For patients with translucent incisal edges, a very thin layer of composite can be placed on the lingual surface of the teeth after bleaching as long as it does not interfere with the bite, so the teeth will not appear to have a bluish, see-through appearance.

Patients with bruxing habits will often have noticeably thicker and darker teeth because of more calcified dentin. These patients will most likely achieve the best results by first using an in-office system and then a high concentration take-home gel for touch-ups.

For parents who are concerned about a child’s yellow or mottled enamel, adult-supervised take-home bleaching kits may be used with the option of chairside bleaching, as it may be performed on anyone with all permanent dentition.

Usually, a low-concentration hydrogen peroxide gel works well for children and teens because they don’t have issues with staining habits or thick, calcified dentin.

Tetracycline stain is the most challenging to remove, but excellent results can be achieved if a patient is willing to put in the time and effort. Because of the banding of this type of stain and the deep-seated hue, the most rapid and dramatic results will be with in-office bleaching.

Depending on the severity of the stain, this procedure may need to be repeated, spacing appointments no sooner than one week apart. Often a patient with tetracycline stains will still need six months or more of home bleaching to achieve a satisfactory shade.

How to approach patients

An easy way to approach patients about bleaching is to make shade assessment part of the recare exam. Patients can be informed that because teeth naturally darken over time, a baseline shade will be recorded.

Keep a shade-guide handy and have it arranged in color value order, rather than the usual ABCD order.

Have the patient agree to the shade and then ask if he or she is interested in bleaching. Because most teeth will change an average of eight to 10 shades, a very significant potential result can be shown to the patient if he or she inquires about the final shade.

Always document final bleaching shades with a photo of the teeth and the matching color swatch from the shade guide, again having the patient agree on the shade.


Teeth bleaching can be a wonderful ‘gateway’ procedure, opening up many other cosmetic options for patients, and is a fun and easy way to increase office production when the entire dental team is on board.

Julie Seager, RDH, BS, is currently practicing dental hygiene in Northern California and is a former RDH Practice Adviser for Discus Dental. Her website is www.hygienescene.com. You may e-mail her at juliecseager@yahoo.com.


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