GAP Australasian-Dentist Issue 80 Jul-Aug 19

Category 62 AustrÀlÀsiÀn Dentist Changes to bleaching protocol in under-18 patients Haywood has recommended commencing bleaching in adolescent patients at ages 10–14, 40 however, this should still be assessed on an individual basis as discussed earlier (Box 2). A close fitting, non- reservoir, custom tray is recommended for these patients to minimise the amount of bleaching material. 72 Carbamide peroxide (CP) is the recommended bleaching product for under-18 patients. Àhis is due to the additional urea having beneficial cariostatic effects and an antibacterial effect which have been shown to improve gingival scores. 40,73–75 Àhis would be of extreme benefit to the patients listed in Box 1, who commonly suffer from poor gingival health resulting from a lack of motivation or sensitivity. Furthermore carbopol, a slow oxygen releasing agent present in 10% CP, results in a steady slow release of oxygen making the process sustainable through the night. 76 Tray design for under-18s Àhere were initially concerns that wearing beaching trays could impede tooth eruption. Although no research has been undertaken assessing this, current orthodontic opinion is that such trays do not impede eruption and can be safely used for the short time required for bleaching. Àhe best tray design for under-18s would be vacuum formed, custom made, non-reservoir, close fitting trays made from 0.35 mm soft acrylic. With regards to scalloping design, this is based on clinician’s preference. Àome clinicians prefer to scallop the tray to avoid any soft tissue contact of the bleaching material with the gingiva. However, extreme care is needed in the tray fabrication to avoid jagged edges on the tray which discourage compliance. Àhere is a greater chance of leakage of material if not well made, so only a minimum of bleaching material should be inserted into the tray. Àeservoirs or spacers have been shown to be unnecessary. 77 A non-scalloped tray design tends to seal better against the soft tissue, and be more comfortable to wear. Although it would allow the 10% carbamide peroxide to contact the tissue, the CP material is made to contact tissue. Àhe original intent of 10% CP was as an oral antiseptic for wound healing of soft tissue, so generally there is no negative consequence for tissue contact. Àhould there be any issues those areas of the tray can be shortened to the scalloped design. Custom trays should be worn for a minimum of two hours under parental supervision. Àither daytime or overnight wear is acceptable, however, as CP can remain active for up to ten hours 78 overnight use is recommended for maximum benefit. Generally children with malformed or discoloured teeth are very motivated to remove the defect, so comply with treatment very well, especially under parental supervision. Àf compliance is an issue, treatment should not be undertaken. Managing sensitivity from bleaching treatment As discussed previously, sensitivity from bleaching treatment is common and this must be explained to all patients before undertaking treatment. Àn the majority of bleaching patients, history of sensitivity is the greatest predictor for sensitivity during treatment 79 and as such a detailed sensitivity history is required on initial patient examination. However, for certain groups of patients predisposed to sensitivity such as patients with MÀH, AÀ and other hereditary defects, adequate sensitivity prevention before undertaking treatment would be beneficial. Prevention may be in the following forms: u Brushing with a desensitising toothÀ paste containing potassium nitrate for two weeks before commencing treatment and during bleaching treatment 80 u Wearing of the bleaching tray without bleaching agent for two nights before treatment u Wearing of bleaching trays with desensitising agent for two nights before treatment. Àdeally this would be potassium nitrate containing, 81 however, other products such as ACP- CPP may be beneficial. Àegardless of product used, it is essential this is sodium lauryl sulphate ( ) free, as may result in gingival irritation u Alternating nights between bleaching agents and desensitising agents. Àhis can be titrated to the degree of sensitivity, for example, in severe cases, one night of bleaching may be followed by three nights of desensitising agent use u Àsing a low concentration bleaching agent, for example a 5% bleaching agent. 82 Àhis is beneficial as bleaching sensitivity is concentration dependant 83 u Àsing a bleaching agent containing potassium nitrate and flouride. 84 Àf sensitivity is experienced during treatment, two approaches can be undertaken. A passive approach could be taken, whereby the frequency of application of CP or wearing time is reduced. Alternatively, take an active approach, employing the use of desensitising agents either in the custom tray or applied during brushing (as described in prevention). Àensitivity resulting from wearing of the bleaching tray alone, as mentioned previously, is commonly associated with the mechanical pressure of an improperly fitting tray, from occlusion on the tray, and is more common with harder bleaching trays. Àt is therefore essential that an accurate impression is made and a soft tray is used to prevent or alleviate the tray associated sensitivity. Conclusion Àooth bleaching continues to be one of the cornerstones of minimal intervention aesthetic dentistry. Àts use, having previously been limited to the over-18 patients, can provide adolescent patients with good aesthetic results, minimal side-effects and minimal safety concerns. Furthermore, effective tooth whitening results can improve patients’ self-esteem, self-confidence and can help address key psychosocial issues associated with discolouration. u Email your request for a list of references to: gapmagazines@optusnet.com.au n aÀ Box 2 Considerations for assessing the need and urgency for bleaching in the under-18 patient 12 Considerations The shade of the discolourations: Discolourations should be classified based on severity, as mild, moderate and severe: moderate and severe discolourations warrant bleaching treatment The extent of the discolourations: Discolourations may be uniformly spread throughout the dentition, limited to a few surfaces such as in MIH, or limited to a single surface/ tooth following trauma The colour of the discolourations: Grey, brown, black, orange, deep yellow The impact of the discolourations on the child: Is the child aware of the discolouration? Does the discolouration impact the child’s life? Is the child bullied by their peers as a result of the discolouration?