If you live in the Northeast as I do, you have had your fair share of snow lately. I LOVE snow...maybe not this much, but why complain? Mother nature's wrath is certainly out of our control. Who doesn't want teeth that are as white as snow?! Well, me, for one. The natural hue of enamel is a mix of yellow, gray, blue and even red. Like skin tone, artificially going too far can look unattractive and unnatural. Over whitening can also damage your teeth. We all remember the mother who was arrested for allegedly allowing her toddler into a tanning booth? Or how about plastic surgery obsessed celebrities who end up looking like bizarre duck-like aliens?
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| White hot...but a bit overdone. www.nbcnews.com |
Having said that, whitening, when done correctly, can look fabulous. After all, your smile is one of the first things people notice when meeting you.
Hands down, the two most talked about topics from people I meet are 1.) whitening and 2.) Invisalign. (We'll save Invisalign for a later post...)
First off, notice that "whitening" and "bleaching" mean two different things in the tooth world. It's a bit confusing for the average patient, I understand.
Whitening Agents:
These products only affect stains embedded in the enamel or superficial pellicle of a tooth. They DO NOT alter the base color a tooth.
Bleaching Agents:
These products not only dissolve surface stains, but they also penetrate the tooth, affecting the base color via powerful oxidizers like carbamide peroxide and hydrogen peroxide.
Imagine that your teeth have pores like your skin. After a facial, the debris and bacteria in the pores are eradicated. The result is smooth, bright, and healthy skin. Temporarily, the oils in your skin have been eliminated. This may be a bad thing . But your skin will re-generate the natural oil layer throughout the course of the day. The same goes for teeth. The pellicle is your jelly-like microscopic layer that protects teeth from acid attacks. It replenishes itself after being removed by brushing or whitening.
Extrinsic stains occur on the surface of teeth, usually from heavy staining food and plaque. These stains can easily be removed by over the counter products and a professional cleaning. Intrinsic stains are tougher - you may need a special internal bleach treatment if it is a root canal tooth. If your staining is from exposure to antibiotics at a young age, often, this requires rigorous bleaching, or most often, a crown or veneer.
**People should know that we do not actually use bleach, otherwise known as sodium hypochlorite, in the whitening products. We use it in root canal disinfection, albeit, at a very diluted concentration and with proper isolation.
Let's play Jeopardy in reverse:
1. "How does bleaching actually work?"
The two main active ingredients are hydrogen peroxide (HP) and carbamide peroxide (CP). HP is three times stronger than CP. So be wary of comparing outright percentages with professional products and over the counter products.
For example, in testing, Crest White Strips are 6% HP. But I'm not so sure I would call it a true bleaching agent. They tend to get most of their whitening effects from disruption of the enamel pellicle -- all that "stuff" layered on your enamel. We don't want to go eradicating the pellicle though. It protects teeth from daily exposures to acid. So all of this acidic action by the strips makes your mouth more acidic, and all of that acid slowly wears down enamel - which can't be replaced! Eventually, the enamel can weaken or cavitate. This is the birth of a cavity.
Bleaching causes a short term weakening of the enamel, unless you use a professional product that has supplemental ingredients that actually strengthen the enamel while oxidizing. One such product is the professional Opalescence gel. We use this product as our "go to" take home gel at the office.
So all in all, the strips aren't bad. In fact, they may be the most convenient way to whiten at home. They certainly are not as effective as professional products, but they are safe for at home use of a non-dental professional when used as instructed.
A lot of times I see patients with an old silver filling (amalgam) that can cause the entire tooth to be gray in appearance. I mean, imagine the appearance of skin around an old tattoo? The ink bleeds and becomes embedded in adjacent pores, etc. The only way to really alleviate the discoloration is to do a crown. If the amalgam filling is only several years old, like my husband's was, we can replace it with a white filling and the tooth looks white again.
2. "How often should I bleach?"
It depends. I know. NOT the answer you wanted, right? It's recommended that after a 14 day cycle of Crest White Strips, you take a two month break. The company that produces Opalescence won't give me a recommendation for duration of treatment for their products. Generally speaking, after patients reach their goal, we have them back off for several months until their recall exam.
Your diet, exposure to tobacco and hygiene all affect how often you bleach as well.
If you do ZOOM in office, we send you home with custom trays and six at home gel applications. I have only ever had one patient go home and decide to whiten right after ZOOM. Once you do ZOOM, you really shouldn't repeat the treatment for at least several years, based on my experiences. You may "touch up" with your at home gel and trays in the months following ZOOM.
3. "I haven't been to the dentist for a few years. I may or may not have cavities, and my gums bleed. But I'm just going to whiten anyway."
OK. Sounds good. you can also get in your car and drive blind folded. Imagine having an open wound on the surface of your skin, but insisting on tanning or waxing first. Sometimes beauty is pain, right? NO! If you have untreated decay, active gum disease (gingivitis), or an abscess, these powerful oxidizers will painfully remind you why you should have gone to the dentist first. They could also inflame the nerve of a tooth causing a root canal down the road. Additionally, how can you fully whiten teeth that are bathed in calculus or plaque? At least the bacteria will look glamorously Hollywood white...
**As a side note, I saw an advertisement for whitening at a tanning salon. As a general rule of thumb, I don't allow anyone who doesn't possess a license of some sort the ability to apply hydrogen peroxide to my body - namely, my teeth and hair. But "it's your funeral" as Dwight from The Office always used to say.
4. "Dentists just want to monopolize the whitening market, and that's why they push more expensive professional products."
I do a fair amount of whitening consults and ZOOM treatments at the office, but it is actually a very low production procedure if you consider chair time (an hour and a half) and purchasing the kits from Phillips Sonicare. We sell pre-formed whitening trays from Opalescence called Tres White, which rivals the Crest white Strips. In my opinion, they are better because of fitting more intimately to the teeth versus the strips. I don't have a problem with Crest White Strips - I have used some myself actually. And if Shakira endorses your product, then I'm SOLD. But if you want the in between spaces and around the gum line whitened well enough, then a custom tray and a stronger bleaching agent is the way to go. If you have gray or blue hues in your teeth, you will need a more aggressive treatment like ZOOM.
If you don't feel like sitting at home, whitening your teeth for 6 hours a night for a week or so, ZOOM is the way to go.
If you don't want to spend hundreds of dollars trying out all the other products, just do ZOOM.
Finally, when is the last time you thought to yourself, "Hey I am SO happy I bought that one-size-fits-all article of clothing or pair of shoes?" Never. These trays are pre-formed for the "average sized mouth." One-size-fits-all really means no-size-fits-any. If you have a small mouth like I do, invest in custom bleach trays.
My sales rep for ZOOM stated that you can get the results you want with at home products just as well as if you did a ZOOM treatment. Research supports this, as well. So you will cross the finish line using either product, but the length of treatment will differ. For example, my husband and I did ZOOM before our wedding in January 2012. I haven't whitened since. I love black coffee and dark chocolate - which I have almost everyday. It was aggressive, and I had definite post-operative tooth sensitivity. This is the most common (and most annoying) side effect. Every patient I have treated in the office has been 100% asymptomatic after 24 hours (approximately 20 cases). I used the UV light treatment in 2012, but our office has since purchased the LED light, which is safer and less aggressive, yielding equal results in my opinion. It also allows me to customize the intensity for each patient.
Why use the light? It has been shown, through research, to accelerate the process of bleaching. There are several other "knock-off" brands that you can utilize for accelerated in-office whitening. ZOOM is the number one patient requested in-office whitening for a reason. It works!
As a caveat:
I take issue with the whitening kiosks at malls or tanning beds, though. These companies get around the law by having you apply the whitening material yourself. The laws on whitening vary state by state, similarly to Botox and dermal filler procedures. Would you go to a salon and paint hydrogen peroxide on your hair yourself... hoping for the best? These places may not adhere to the strict guidelines of the CDC, and you may suffer a soft tissue burn or irreversible damage to teeth. The employees aren't subject to any rigorous testing and licensing by the state. I worry about the level of safety and precaution given to these patients. Anyone can hide behind a 30,000 word "signed consent," but really, come on? Just like anything, you can overdo it. Too much whitening damages teeth. But how can one's safety be properly assessed without a proper and complete dental exam?
It's unethical to, according to the ADA, whiten a patient who has active or untreated gum disease or cavities. How would a teenager working a part time job at the mall on the weekend supposed to know this? What if you are pregnant, lactating, take photosensitive drugs or have other medical issues?
If this sounds like I still want to simply monopolize the whitening market, then you got me.
5. "I have sensitive teeth. Can I still whiten?"
Sure. So do I, but I used a professional grade anti-sensitivity tooth paste before doing so and it really helped. An important de-sensitizer is potassium nitrate. It's found in Sensodyne and other anti-sensitivity products but in weaker concentrations versus the prescription kind. You may have other issues like abfraction lesions (notched out roots) or cracked teeth that will need to be selectively isolated during ZOOM. Again, not something that I want a non-professional trying to do. If you have extensive sensitivity problems, ZOOM should be avoided. I'd recommend a product like Opalescence take home gel - which has some de-sensitizers built into it. If you try out the weakest percentage and you still can't stand it, then STOP. You shouldn't go through enormous pain to whiten. Look at other options after discussing your concerns with your dentist.
6. "How much does it cost? Does insurance cover it?"
Unfortunately, dental "insurance" does not cover this cosmetic, elective procedure. It's similar to wondering why health insurance doesn't cover elective Botox or dermal filler procedures. It would be FABULOUS, but hard to justify why it's of equal importance to other active disease processes. (We will discuss why dental insurance really isn't insurance on another post.)
You get what you pay for. The most aggressive and effective whitening treatment we offer is ZOOM. The HP content is 25% to 38%. It's by no mistake that it's the most expensive. But it works. Depending on the case, it will run you several hundred dollars. You also get 6 at home treatments and custom trays with ZOOM.
The next step down is the at home Opalescence gel with custom trays. We offer 10%, 15% and 35% CP formulations. This will run about $150 less than the ZOOM treatment. Great results as well. You just need to be compliant. The next product is TresWhite. You get 10 pre-loaded, pre-formed trays. You only have to wear them for 15-30 minutes a day. We offer 15% HP strength.
7. "How many shades whiter will I get?"
Good question. Most dental professionals utilize the Vita Classic Shade guide to record crown shades and whitening shades. I'm not sure which shade guide the evaluators use for Crest White Strips, but to "guarantee" so many shades lighter, is tough. Depending on the shade scale, you could claim that the whitening spans far more than what I would claim based upon the Vita scale. There are A,B,C and D ranges for tooth shade. We even utilize Bleach shades for those people who go "off the scale."
If you are a A or B range before whitening, you will lighten up very nicely. These are the people with yellowing from extrinsic staining. The only exception would be those who have lost enamel due to erosion or abrasion. If you have lost enamel, you have lost the ability to whiten effectively.
If you are a C or D range, you will not whiten easily. These people have deeper gray or even dark red undertones. It would be reasonable to expect to get to a C1 if you start out as a C3, for example. Some patients actually jump up to a bleach shade. If this is you, you really need to try ZOOM or a rigorous whitening program, minus any extreme sensitivity issues.
I'd be remiss without mentioning dark staining food and tobacco products. The more you use these items, the more you will have to update your whitening. Avoid them while you are whitening. It's like clogging up your pores with sweat and oil right after a facial. The teeth become very "porous" after whitening, so don't clog them up with stains and impurities right away!
So let it snow, let it snow. Go ahead and whiten and lighten. Just be careful with whatever product you use to brighten.
Jacquline R. Owens, DMD, MBE
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