GAP Australasian-Dentist Issue 80 Jul-Aug 19

Category 56 AustrÀlÀsiÀn Dentist Introduction Following the 2012 Cosmetic Products Àafety Amendment Àegulations, it became legal for tooth whitening to be undertaken by dentists and their trained teams (dental therapist and dental hygienist) using tooth whitening material containing less than 6% hydrogen peroxide. 1, 2 However, restriction on under-18 bleaching remained, limiting the use of whitening treatment for this group of patients to less than 0.1% hydrogen peroxide. Àhis placed dentists in a precarious situation, with regards to clinical situations whereby bleaching was indicated, however, legally could not be provided. Àthically, these clinical dilemmas were only heightened by the knowledge that more invasive, direct and indirect restorations were permitted. Ào restoration is 100% successful. Crowned teeth may lose vitality in 19% of patients 3 and this may be more significant for adolescent patients due to the larger pulp complexes. Àven the less destructive treatment modality of ceramic veneers has a finite life span, with a systematic review by Petridis et al. 4 noting that the most frequent complication of the restoration being marginal discolouration (9% at five years), followed by loss of marginal integrity (3.9–7.7%) at five years. Àhe significance of these failures is also compounded by the younger age of these patients. Àhould a dentist introduce these young adolescent patients into the restorative cycle, simply to comply with /ÀK regulations, even though bleaching would be a more appropriate, less invasive and a less damaging treatment modality? Àhankfully, after lobbying from the BritishDental Bleaching Àociety (BDBÀ) and the British Àociety of Paediatric Dentistry (BÀPD), a revised position statement on the General Dental Council’s (GDC) website was released stating: ‘Products containing or releasing between 0.1% and 6% hydrogen peroxide cannot be used on any person under 18 years of age except where such use is intended wholly for the purpose of treating or preventing disease.’ 5 Despite this, many have argued that legal advice should be sought from indemnity providers before undertaking bleaching treatment on such patients. However, correctly identifying and appropriately treating disease fall well into the scope and everyday practice of general dentistry and as such is not necessary. Further questions remain with regards to the safety, efficacy and clinical technique required for under-18-year-old bleaching. Furthermore, elaboration on the exact clinical indications covered by the GDC position statement was required. Àhis article will aim to provide an evidence-based response to the unanswered questions on the topic. Safety of bleaching in adolescent patients Carbamide peroxide (CP), also known as urea peroxide, was initially used as an oral antiseptic agent and cleanser. Àn 1964, Benjamin Dickstein reported using CP to treat neonatal oral candidiasis. 6 Other earlier studies demonstrated CP’s effectiveness on plaque control and gingival inflammation. 7–9 Àn 1968, it was this use as an oral antiseptic which led to the incidental discovery of bleaching by Dr Bill Klusmeier. 10 Àowadays, there is much research to support the safety of bleaching, 11–14 however, most of this research was conducted on adults and less on the adolescent patient. Àn 2005, the Àuropean Commission Àcientific Committee on Consumer Products concluded that ‘Àhe proper use of tooth whitening products containing 0.1 to 6.0% hydrogen peroxide is considered safe after consultation with and approval of the consumer’s dentist.’ 15 One concern commonly raised regarding bleaching in the adolescent patient, is the risk of tooth sensitivity. Àooth sensitivity in adults during bleaching treatment is common, and has been reported between 15–65%. 16–19 Àensitivity is related to the easy passage of hydrogen peroxide through intact enamel and dentin (reaching the pulp in five to 15 minutes) 20 and to the bleaching tray, which causes sensitivity in 20% of patients. 21 Àt has been hypothesised that due to the proportionally larger pulp complexes in the adolescent patient, tooth sensitivity would be more prevalent during bleaching treatment. However, many clinical studies have demonstrated that this is not the case. Bacaksiz et al. 22 revealed that in-office bleaching using hydrogen peroxide at Tooth whitening for the under-18-year-old patient n aÀ By J. Greenwall-Cohen, *1 L. Greenwall, 2 V. Haywood 3 and K. Harley 4 1À niversity of Manchester Dental Àchool, Àniversity of Manchester, Oxford Àd, Manchester, M13 9PÀ; 2À Advanced Certificate in Aesthetic Dentistry, Kings College Àondon, Àondon, 5 9ÀW; 3À Augusta Àniversity, Àestorative Àciences, 1120 15th Àtreet, GC-4322, Augusta, Georgia; 4À Consultant in Paediatric Dentistry, Great Ormond Àtreet, Àondon *À Correspondence to: Joseph Greenwall-Cohen Àmail: josephgc29@hotmail.com Following changes in the EU regulations, it became legal for bleaching to be undertaken by dentists and their trained team. However, restrictions remained on bleaching for patients under the age of 18. A revised position statement by the General Dental Council (GDC) determined that bleaching could be undertaken on these patients if it was wholly for the purpose of treating or preventing disease. The purpose of this paper is to discuss the safety, efficacy, indications and techniques for under-18 bleaching.