GAP Australasian-Dentist Issue 80 Jul-Aug 19

Category 58 AustrÀlÀsiÀn Dentist n aÀ high concentrations (25% and 36%) could be undertaken safely on the adolescent patient. Furthermore, several randomised control trials by Donly have shown that tooth sensitivity was relatively minor in adolescent patients in comparison to reported sensitivity among adult patients, 23–27 despite greater than normal hydrogen peroxide concentrations being used (6.5%, 9%, 10%). Àhis could be attributed to the increased enamel quantity and quality of the adolescent teeth and also to the larger pulp complexes in adolescent patients’ teeth which allow faster recovery from the acute inflammation experienced during a sensitivity episode. 27 Àmportantly, the sensitivity experienced by the under-18 patients is manageable and does not deter them from completing the tooth whitening treatment. 12 Gingival irritation is another reported side effect associated with adolescent treatment. 23–27 Gingival irritation is more common in higher concentrations of bleaching products and may be more common among strip-applied bleaching agent in comparison to tray-applied. 28 For most patients, gingival irritation is tolerable and is not a barrier to completing the treatment. An ill-fitting tray is usually the primary cause for the irritation and the problem is usually resolved by relieving overextensions of the tray. Furthermore, failure to wipe away excess whitening product may result in gingival irritation and therefore it is essential that this is clearly explained to the patient and their supervising parent on delivery of the tray. 13 Effectiveness of under-18 bleaching Àignificant bleaching effects following treatment have been repeatedly demonstrated when compared to baselines in clinical trials. 23–27 Àhere have been some suggestions that the bleaching success and rate of bleaching may be increased in the adolescent patient, when compared to the adult patient. Àhis may be due to the increased permeability of the dentine and enamel and the diffusion Fig. 1 a) Labial view of severely discoloured maxillary central incisors. b) Labial view of the incisors following three weeks of bleaching. c) Labial view of maxillary incisors following ten weeks of bleaching a b c flux experienced due to the anatomy of the younger enamel structure, which is more porous and permeable. 29 Àhe young teeth have also had less time in the mouth to acquire stains or deposit secondary dentin. Àhere may also be improved compliance resulting from social pressures experienced in the adolescent age group, however, there is currently no research on this theory. Indications for bleaching in children and the adolescent patients Àhe GDC guidance mentioned previously states that products containing or releasing 0.1–6% hydrogen peroxide can be used in under-18 patients, only ‘for the purpose of treating or preventing disease’. 4 Guidance on the indications and conditions for adolescent bleaching have been listed in Box 1. Àome may suggest that discolouration may not fall under the classification of disease, however, it is prudent to understand the psychological and psychosocial effects associated with discolouration 30,31 and the emotional effect on a child resulting from delayed treatment of the discolouration. 32 Àegative self-image due to a discoloured tooth or teeth can have serious consequences on adolescents. As such, treating discolouration and disease may aid in prevention of bullying and Fig. 2 a) Labial view of teeth in occlusion demonstrating fluorosis discolouration of the dentition and existing composite restorations. b) Labial view of teeth in occlusion following successful treatment with bleaching and composite replacement Fig. 3 a) Labial view of teeth demonstrating fluorosis discolouration of the dentition. b) Labial view of the result post bleaching and microabrasion treatment Fig. 4 A labial view of central incisors presenting with white markings along the perikymata. This was believed to have resulted from amoxicillin which was administered to the child at a young age a a b b