Clinical & Legal Considerations Aidan Hannah Tooth Whitening Clinical & Legal Considerations Aidan Hannah

Contents Introduction Legal Aspects Clinical Aspects Vital Bleaching Non-Vital Bleaching Alternatives References

Introduction Increased prevalence – celebrities etc. Staining Extrinsic – Dietary, Smoking, Chlorhexidine Intrinsic – Developmental (Fluorosis, Tetracycline, Amelogenesis Imperfecta) Loss of Vitality

Legal Aspects GDC Indemnity/Insurance Defined as ‘the practice of dentistry’ Dentists, Therapists, Hygienists & Clinical Dental Technicians Ethical obligations as per any treatment i.e. Act in patient’s best interest, obtain fully informed consent, have valid medical history Indemnity/Insurance Check with your provider – registration at risk if practicing without appropriate cover Practice of dentistry – only GDC registrants Ther/Hyg/CDT require prescription from dentist – ‘additional skill’ Nurses can take imps with additional skill Different organisations can have different rules/levels of cover

EU Governance on tooth whitening products EU Council Directive 2011/84/EU in effect from Oct 2012 18+ years old 0.1-6% Hydrogen Peroxide (present or released by other compounds) To be sold only to dental practitioners, first use limited to them; can then provide access for patients thereafter Effect of Brexit? 16% carbamide peroxide releases <6% hydrogen peroxide First use by dentist/under direct supervision – demonstrate in chair Advise pt’s of harm of buying from unregulated source Brexit - Watch this space

Glasgow girl on FB recently – woman working from home, no exam/Qs etc Glasgow girl on FB recently – woman working from home, no exam/Qs etc. Gel applied every 15mins for 1 hour Numbness/swelling/pain/ulceration/burning sensation for days GDH Dx 3rd degree burns/possible allergic reaction

Clinical Aspects Case Selection Thorough exam first Anterior restorations? Predictable outcome? - acquired/mild developmental stains Vital vs Non-Vital Informed Consent - contemporaneous notes Wait ~1 week after finishing before commencing any restorative work involving bonding Severe discolouration/extensively restored prob better with restorative option Consent – other options, risks (sensitivity, transiently white gngivae), benefits (conservative of tooth tissue), costs, lifespan of result (1-3 years), effect on restorations – may need replaced afterwards/trays may not fit again after this Main side-effect is sensitivity due to pH opening dentinal tubules. Effects usually short-lived

Treatment Options Vital Bleaching At home using vacuum-formed splint Indicate extensions eg. to distal of 6s Worn for 2-3 hours/8 hours depending on product Demonstration by dentist first Matchstick-head size amount on labial aspect of tray (Most commonly carbamide peroxide) Usually results within 2 weeks, although could take longer - review Take shade at start/finish

Patient Information: Brush teeth first Wear 2-3hours/8hours (overnight) depending on product Apply matchstick-head amount to labial aspect No eating/drinking during wear Rinse with water after Use sensitive toothpaste – if sensitivity occurs, use on alternate nights Minimal contact with red wine/coffee/tobacco to prolong effects

Non-Vital Bleaching Good option if only 1 tooth discoloured/tooth minimally restored – avoids use of more destructive restoration GP removed to below gingival margin, sealed Bleaching agent (most commonly sodium perborate) packed against labial wall, sealed in with temporary restoration for 2 weeks Repeat until desired shade reached Some etch pulp chamber first, however no evidence to support efficacy

Alternative Treatment Options Micro-abrasion (superficial only) Scale & Polish (surface stains) Permanent restoration Leave alone...

References Advanced Operative Dentistry. D.Ricketts & D.Bartlett www.gdc-uk.org www.dentalprotection.org