For many patients, a brighter, whiter smile is easily achievable.
For others, discoloration such as white spots, can mean whiter teeth prove more difficult to achieve.
There are many excellent whitening treatments available on the market, and it is important you make the right decision for your patient.
One treatment option for white spots involves teeth whitening with either Hydrogen Peroxide or Carbamide Peroxide to break up stains. This, in combination with additional treatment such as resin infiltration; can result in a dramatically whitened smile.
This clinical case reviews the results of bleaching therapy using White Dental Beauty Carbamide Peroxide 10% for 20 days.
Jordi Manauta: Infiltrate and Restore
Jordi Manauta is an experienced dentist, who is is engaged in the ongoing development of various materials and instruments for aesthetic dentistry and photography in collaboration with international companies.
Born in Mexico City, Jordi Manauta graduated with a degree in dentistry from the Technological University of Mexico (UNITEC) with distinction and was apprentice to Dr Miguel Angel Tamés (Mexico) and Dr Walter Devoto (Italy). He continued his postgraduate studies in Operative and Aesthetics Dentistry Master in UIC (Universitat Internacional de Catalunya) in Barcelona.
Dr Manauta is the author of the book Layers (Quintessence 2012). In addition to the many publications he has authored and co-authored, Dr Manauta is also frequently invited to lecture. He also currently works full time at his private practice.
Bleaching Therapy
Bleaching is no longer a vanity procedure. For many years, the benefits of non-invasive techniques have been proven to deliver amazing results, when the indications are followed correctly. The use of bleaching therapy to diminish and treat white spots is not without controversy, being rejected by some, but adopted by many others.
The Infiltration technique has been widely proven to eliminate unsightly enamel spots, if the depth is correctly evaluated and the indications are followed correctly; for example in deep lesions, infiltration used in isolation is likely to be ineffective.
In the author's experience, bleaching of white and amber spots before treatment has been a winning strategy and the following points have been noted:
- Amber spots: Generally, these turn into white spots, which are more susceptible to the acid treatment of Infiltration therapy.
- White Spots: Two phenomena happen in these cases, the first is a reduction in opacity due to a balance in the refraction index of the disarranged prisms. And the second, is that little or no bleaching occurs to the white spot. This enables it to blend better due to the low contrast between the newly bleached surrounding tissues and the white spot itself.
Bleaching Therapy with White Dental Beauty
White Dental Beauty has a range of high quality tooth whitening gels includes 6% hydrogen peroxide and 5% 10% & 16% carbamide peroxide with NOVON, providing great versatility and clinical freedom to whiten patients’ teeth with as little as 30 minutes a day active treatment. Powered by NOVON, which uses an intelligent pH acceleration for maximum whitening effect, speeding up the whitening process whilst still being highly effective.
NOVON is a new, patented whitening compound that comprises hydrogen peroxide, urea and sodium tripolyphosphate and is the active ingredient in a new generation of tooth whitening gels. NOVON has a unique inherent feature in that, on application, it produces a ‘pH jump’ into the alkaline pH range. This ‘pH jump’ enhances the release of perhydroxyl ions which give a faster whitening effect. NOVON – containing gels can therefore produce a similar whitening effect within a shorter timeframe, in comparison to whitening using a regular gel. Alternatively, within the same time frame, a similar level of whitening can be achieved using a lower concentration of NOVON (Hyland et al., 2014). This should be an advantage to patients with sensitive teeth.
NOVON has 4 options for home bleaching:
- 6% Hydrogen Peroxide from as little as 30 minutes a day
- 16% Carbamide Peroxide from as little as 60 minutes a day
- 10% Carbamide Peroxide 2-4 hours overnight
- 5% Mild Carbamide Peroxide 2 hours a day
In this case, the selected bleaching therapy was White Dental Beauty Carbamide Peroxide 10% for 20 days.
Bleaching in Progress
Initial evaluation of the patient. 23-year-old woman, very dissatisfied with the present situation and the aggressive treatment option she had been recommended (Fig 1.)
A cross-polarized picture is taken to better assess the extent of the lesion. Trans-illumination is used to estimate the depth of the lesion (not shown). It is decided to start a bleaching therapy to try and minimize the contrast between the spots and the tooth, and to bleach the amber spots (Fig 2.)
Bleaching trays must be extremely precise, cervical sealing must be perfect in order to keep the bleaching product in place and away from intraoral moisture (Fig 3.)
Fitting of the bleaching tray. The selected bleaching therapy was Carbamide Peroxide 10% for 20 days (White Dental Beauty, Optident) worn during sleep. No sensitivity was reported and we are increasingly seeing this phenomenon with the new generation of products. (Fig 4.)
Progress Review - A Comparison
After 20 days bleaching. Picture with lateral flashes (Fig 5.)
Cross polarized image showing the latest situation. Some spots have vanished, the amber spots have turned white and other spots have softened in saturation (Fig 6.)
Adjacent comparison, note the amber spot (Fig 7.)
Mirror like comparison (Fig 8.)
Mirror-like comparison of before bleaching (lower) and after (upper) with Deep-view contrast (Fig 9.)
Post Bleaching Evaluation & Additional Treatment
Post-bleaching evaluation, the patient starts treatment with resin infiltration. The first step is to isolate using rubber dam. (Fig 10.)
15% Hydrochloric acid application for 2 minutes (ICON ETCH, DMG, Germany). This step can be repeated up to 4 times. Increasing application frequency runs the risk of deeply eroding the teeth. (Fig 11.)
Air drying, note how the spots become tremendously white.(Fig 12.)
Treat with alcohol (ICON dry, DMG, Germany). Manufacturer suggests a 30 second application of this agent. This is the result after 30 seconds (Fig 13.)
In the author's experience, this product applied for 2 minutes gives a better penetration and thus a better preview of the real outcome. At this stage the clinician should decide whether to repeat the full erosion cycle or start the resin infiltration. (Fig 14.)
Air drying of alcohol is very easy and, if the previous step was successful, infiltration can begin. (Fig 15.)
Erosion is visible, especially when completing 4 cycles or more. (Fig 16.)
Resin infiltration. The resin has extremely low density and is solvent free and therefore able to penetrate as much as the alcohol. It is advisable to keep the lights low and allow the material to penetrate for about 3 minutes; failure to do so may result in an incomplete infiltration and a different result than the one obtained in the preview with the ICON dry (Fig 17.)
After infiltration, a small layer of enamel is placed to cover up the erosion caused during therapy (Fig 18.)
Polishing is mandatory with or without the use of a final composite layer (Fig 19.)
Final Results
Final result after 3 weeks (Fig 20.)
Cross polarization image, shows a good result, which is not excellent, but not visible to the naked eye. (Fig 21.)
Deep-view contrast of the final situation (increase in contrast, decrease in brightness of the digital image) helps in analyzing the picture and allows a true assessment of the remaining lesions. (Fig 22.)
Deep-view contrast of the initial situation (Fig 23.)
Mirror-like comparison of before (lower) and after (upper) treatment. (Fig 24.)
A similar case was planned to be treated in the same way, but after 30 days bleaching, all the spots had disappeared (digital mock-up, right hand side shows before the treatment, left hand side shows after treatment). (Fig 25.)
Bleaching should be a mandatory resource before stain treatment and restorative therapy. There is little awareness in the profession of the benefits of bleaching and some of the harmless side effects are also feared. Infiltration therapy should be a first-choice treatment, together with bleaching for these cases. ICON dry, which is used as a preview of the resin filtration after erosion, should be applied for 2 minutes to obtain proper visual assessment. ICON infiltration resin has to penetrate completely and a 3-minute application is advised.
Below, the comparison between the initial situation (Fig 23.) and the final result after 3 weeks (Fig. 20.)
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White Dental Beauty Gels are specifically formulated, packaged and delivered with your patients in mind, ensuring you have everything you need to offer them a successful whitening treatment.
White Dental Beauty's whitening products are available worldwide from your local distributor including Optident for the UK. To order in the UK visit the White Dental Beauty manufacturer page or call +44 (0) 1943 60 50 50.
