DentalCare What to Know About Whitening Instructions

What to Know About Whitening
Instruction Manual

What to Know About Whitening

Course Author(s): Lesley McGovern Kupiec, RDH, MSDH; Jane L. Forrest, EdD, BSDH
CE Credits: 2 hour
Intended Audience: Dentists, Dental Hygienists, Dental
Assistants, Office Managers, Dental Students, Dental Hygiene
Students, Dental Assistant Students
Date Course Online: 11/17/2022
Last Revision Date: N/A
Course Expiration Date: 11/16/2025
Cost: Free
Method: Self-instructional
AGD Subject Code(s): 780

Online Course: www.dentalcare.com/en-us/ce- courses/ce491
Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound  evidence-based dentistry should be used in patient therapy.

Conflict of Interest Disclosure Statement

• Lesley Kupiec worked part-time as a dental hygiene educator for P&G.
• Jane Forrest has done consulting work for P&G.

Overview
As an oral health care professional, it is important to understand what it means to whiten teeth.
This course will review the differences between whitening and bleaching and how to identify types of stains or causes of tooth discoloration, how to properly include  whitening in individual treatment plans, and how to discuss the options, benefits and potential adverse effects.

Course Contents

• Introduction

• Learning Objectives

• What is the Difference Between Whitening and Bleaching?

• Staining Types and Causes

• Indications for Bleaching

• Four Categories of Whitening Options including Pros and Cons

• Professionally Applied In-office

• Professionally Dispensed Take-home

• Consumer Purchased Over-the-counter (OTC)

• Non-dental Options

• Side Effects

• ADA Seal of Acceptance

• Whitening in Action: Role of Dental
  Professionals in Assessing and
  Recommending Appropriate Options

• Case Scenario 1: Whitening – High School Reunion

• Case Scenario 2: Periodontal Disease – Smoker

• Case Scenario 3: Child in Mixed Dentition

• Conclusion

• Course Test

• References

• About the Authors

Introduction

Do your patients often ask you about whitening their teeth? How prepared do you feel to answer their questions? Tooth whitening or bleaching is one of the most frequently requested dental procedures. The increase in demand for tooth whitening is keeping pace with both the advances in techniques for vital tooth bleaching and the media focus  on white smiles. Advancements in technology allow us to see color in high definition which makes the public more aware of their appearance and self-conscious of yellow or  stained teeth.1 According to the American Academy of Cosmetic Dentistry, when patients were asked what they would like to improve about their smile it was to have whiter,  brighter teeth. Patients also most commonly reported that discolored, yellow or stained teeth are what makes a smile unattractive.2 With the introduction of at-home custom tray bleaching in the late eighties, the tooth whitening industry has grown with more products and procedures demonstrated by current research to be safe and  effective options. 1,3 In 2000, a strip-based whitening system was introduced, Crest® Whitestrips™ as a convenient alternative for at-home bleaching rather than using a  custom tray. Whitening procedures also can be administered in-office or in combination with at-home methods. In addition, there are over-the-counter (OTC) products, from  simple, inexpensive options such as AuraGlow®  Teeth Whitening Pen to more advanced products like GLO Lit™ Teeth Whitening Tech Kits. Individuals may  purchase these without input from a dental professional and more recently, other non-dental options, such as kiosks in malls and spas have expanded the market for tooth  whitening.

Learning Objectives
Upon completion of this course, the dental professional should be able to:

• Explain the difference between whitening and bleaching.
• Discuss the etiology of intrinsic and extrinsic stains.
• Identify indications and contraindications for bleaching.
• Discuss the 4 categories of whitening options.
• Discuss the pros and cons for each of the 4 categories of whitening options.
• Discuss the possible side-effects of bleaching.
• Given case scenarios, apply criteria in determining whether candidates qualify for bleaching.

What is the Difference Between
Whitening and Bleaching?
The terms whitening and bleaching are often used interchangeably, however there is a difference. Whitening is the umbrella term whereas bleaching is one form of whitening.  Teeth can be whitened by physical removal of superficial stains using abrasive agents such as toothpaste or prophy paste, or through bleaching processes, which rely on  chemicals to penetrate enamel and dentine.
Peroxide
based whitening products work to remove the appearance of stain through a redox chemical reaction. Free radicals are produced when the oxidizing agent hydrogen peroxide  (HP) breaks down. These free radicals are then available to react with organic molecules in enamel and dentine, breaking down the double bonds of the chromogens (color  causing agents). These new, simpler molecules reflect light differently resulting in the appearance of whiter teeth. 1,4 The active ingredient found in most bleaching agents is  hydrogen peroxide (HP), which can be delivered as HP or as carbamide peroxide (CP). CP is a stable compound which in contact with water will break down into HP and  urea. 1 For example, 10% CP breaks down into about 3% HP and 7% urea. 3,5 Consequently, this breakdown process results in a slower release of the HP, and typically requires longer wear times for individuals using CP bleaching agents.

Indications for Bleaching

While many patients might be curious about whitening their teeth, dental professionals need to understand who the ideal candidates for whitening are and when/how to  include bleaching in a treatment plan. A full oral examination that includes checking the medical history and noting potential allergies, asking

Table 1. Types of Tooth Stains.6

if there is a history of tooth sensitivity, finding out the possible etiology of stain, and checking for any signs of potential infections or oral disease are necessary to start the  process. 3
An ideal candidate for whitening will be a healthy individual with a complete permanent dentition, preferably someone at least 14 years of age. The individual also must have  the desire to be compliant and follow directions, as well as the capacity to understand potential side effects and how to manage them. It is best to avoid the contraindications  listed in Table 2.

Four Categories of Whitening Options including Pros and Cons
When it comes to deciding what option may be best for a patient, it is important to incorporate the most current scientific evidence along with your clinical experience and  the patient’s preferences, values and clinical circumstances.
When available, a clinical practice guideline(s) should be reviewed to see if it covers the patient’s specific conditions. Since whitening has been a hot topic in dentistry for  several years, a considerable amount of research has been conducted on various whitening options, including treatment time, wear time, frequency and dosage or  concentration of the active agent, i.e., HP. 12-21 Whitening procedures can be placed into four categories: professionally applied in-office, professionally dispensed patient  take-home, consumer purchased over-the-counter (OTC), and non-dental options. 3

Professionally Applied In-office
Description: Many dental offices offer chairside bleaching options for patients.
Typically, in-office bleaching is performed with a high concentration of HP ranging from 25-40%. 7 This procedure is monitored by a dental professional and precautions are  taken to minimize sensitivity and gingival irritation by protecting the soft tissues with isolation techniques. 3,7 Whitening may occur after one treatment, however the desired  results may take several visits. After initial in-office bleaching there may be some rebound of the color, which explains why multiple visits may be necessary and why some dentists may fabricate take-home trays for patients to use to lock in the shade.

Light sources, including lasers, light emitting diodes (LEDs), plasma arc lamps (PACs) and halogen lamps are used with some in-office techniques and products in  combination with in-office HP whitening procedures.22
The theory behind using a light source is  that by heating the HP gel, the free radicals are made available faster, thus resulting in more effective whitening. However, results of  a recent meta-analysis did not confirm this outcome for in-office bleaching gels with either high or low levels of HP, and the authors stated that it allowed them to “… determine that light-activated bleaching (regardless of light source and protocol) is similar to the use of HP alone (regardless of protocol) in terms of color change.” 22  In  addition, they found that the risk of tooth sensitivity was not influenced by light sources. However, a new systematic review found some evidence that laser may reduce  sensitivity, especially when higher concentrations of HP are used, but offers comparable bleaching results without use of laser. 20 Overall, lower concentrations of HP should  be considered for in office bleaching since they have similar color change efficacy with less risk of adverse reactions. 21
When comparing in-office to at-home bleaching, there is no conclusive evidence of increased risk or intensity of tooth sensitivity or better efficacy for in- office bleaching.
14,18

Pros: Initial assessment to determine causes of discoloration and clinical concerns; professional supervision and soft tissue protection; and, quickest results.
Cons: Most expensive option; may result in more sensitivity when a high concentration of HP is used; 7,14 the dentist (not patient) controls the outcome when bleaching is  completed in the office; and, may need multiple sessions and supplemental take-home trays to accomplish desired results. 3,7Professionally Dispensed Take-home Description: The most common professionally dispensed whitening system is custom fitted bleaching trays made in-office. An appropriate

Table 2. Contraindications for Teeth Bleaching.

Consumer Purchased Over-the-counter (OTC)
Description: OTC bleaching products are readily available and continue to gain popularity. 7 They consist of lower concentrations of HP and are applied by the patient  through prefabricated trays, brushing a paint-on gel, or placing whitening strips. 1,5 Daily wear times may vary, yet most require their application over a 2-week period to see a  change in color by 1 to 2 shades. 1
Whitening mouthrinses, chewing gums and toothpastes also can be purchased OTC. 4,5 OTC whitening products have been used for years demonstrating safety.
When compared to a placebo, several studies found that all OTC whitening products had superior whitening efficacy. 5 Of the 71 studies included in a recent Cochrane  review, 26 compared a whitening technique to a placebo (vs. another whitening technique) and found similar results over a short period of time, although the evidence was  low to very low. 5
For the remaining studies that did compare one bleaching agent to another bleaching agent, the variation in study designs did not make it possible to draw any conclusions  regarding which application method, percent concentration, or duration time was superior. Consequently, the review recommended standardizing study protocols so that  future research results could be compared.
Pros: Least expensive option, easy access to products, high degree of safety.
Cons: Lack professional supervision (which can result  in adverse effects or mismanaged expectations); individuals must be compliant; OTC trays are not custom fit and may be uncomfortable; people with crowded or overlapped teeth may see poor results. 5

Non-dental Options
Description: Over the past decade nondental venues, such as mall kiosks or spas have become popular places for teeth bleaching. These options offer convenience and can provide this service without dental professionals by loading bleach in a tray then allowing individuals to administer the product to themselves. 26 It is important to advise patients of the importance of professional dental supervision when bleaching. An issue with non-dental venues is that it may give the appearance of a professional setting, with.

Table 3. Summary of Pros and Cons for 4 Categories of Whitening Options.

some employees wearing scrubs or lab coats.
However, most do not have the education or training to help someone who may have contraindications to bleaching or experience adverse side effects. 3,26,27
Pros: Access, convenience, less expensive than in-office.
Cons: Unsupervised by professionals and unregulated; gives appearance of providing professional treatment. Employees of the kiosks or spas typically do not have the  education to determine an individual’s contraindications to bleaching or manage an adverse reaction.
Side Effects
All bleaching methods have the potential to cause some side effects, although not all patients will experience them. The most commonly reported side effects are increased tooth sensitivity and gingival irritation. 1,3,8,9,13,28,29
Side effects tend to be short lived, clearing up after bleaching is stopped. Effects of bleaching have been studied for 30 years and there have been no long-term systemic or  oral health issues discovered.
Tooth Sensitivity: Patients should be advised that tooth sensitivity is a common side effect of the tooth bleaching process. It can happen early in the process, therefore,  taking steps to minimize potential sensitivity before it starts will benefit the patient as it is always better to prevent than treat after the fact. Sensitivity may occur if the flow of  fluid within dentinal tubules increases. When tubules are occluded, e.g., by smear plugs, there is less flow of fluid. However, during the bleaching process oxygenation occurs, which results in the removal of smear plugs. Consequently, transient sensitivity may occur for some. 30
Whether one experiences sensitivity depends on different factors such as: concentration of the bleaching agent, contact time of bleach on the tooth, frequency of bleaching,  and an individual’s susceptibility to sensitivity/history of sensitive teeth. 1,3,8,28 Although systematic reviews /meta-analysis have not shown significant differences in tooth  sensitivity comparing in-office and at-home techniques, lower concentrations (10% CP) are typically

ADA Seal of Acceptance

The dental professional should be knowledgeable about available whitening options for patients, whether they be professionally dispensed or an OTC option.
When making suggestions for safe and effective OTC products, dental professionals can confidently recommend those which have earned the ADA Seal of Acceptance.33

The ADA has recently expanded the Seal of Acceptance program to include OTC bleaching products. In 2017, the first home use bleaching product, Crest® 3D Whitestrips™ (Glamorous White), received the ADA Seal of Acceptance. Since then, two other Crest Whitestrip products have earned the Seal, 3D Classic Whitestrips Vivid  and 3D Whitestrips Gentle. 34
This means they have met the criteria for safety and efficacy that the ADA requires. When this course was developed, no other bleaching/whitening products were listed as  meeting the ADA Seal Program’s general criteria for Acceptance. For more information on the ADA Seal of Acceptance program and process of earning the ADA Seal please refer to the ADA’s website.

Whitening in Action: Role of Dental Professionals in Assessing and Recommending Appropriate Options
Case Scenario 1: Whitening – High School Reunion
Mr. Jim Hartwell, is a 38-year old accountant.
His chief complaint is the yellowing of his front teeth, which he feels is getting worse as he gets older. He would like them whitened within three weeks before he attends his  20-year high school reunion. When reviewing his health history and behaviors, you learn that Mr. Hartwell drinks coffee and enjoys red wine.
After reviewing his health history and completing an oral assessment, you determine his only treatment needs are preventive care and suggest re- evaluating the discoloration  at the end of the appointment since the yellow stain could be removed during his prophylaxis.
If additional whitening is needed, making him custom trays for use with an at- home whitening/bleaching system will meet his time requirement. He asks if there are any other options and mentioned he tried whitening strips about 10 years ago, but said he wasn’t very compliant since he experienced some sensitivity.
However, he now claims to be very motivated and wonders if he should try them again.
You explain several options, including the whitening strips and present the pros, cons and cost.

• In-office – most expensive, quickest results, compliance is not as necessary.
• Custom take-home trays – medium expense, compliance is necessary, 10% CP may have least side effects. 17
• Whitestrips – least expensive option, compliance is necessary.
  All options could get him to his desired whiteness, but he has to take into account time, cost and compliance factors. You also inform him that all options may have side effects, such as tooth sensitivity and/or gingival irritation. If these are a concern, then 10% carbamide might be best option at home with compliance.17
  In addition, fluoride varnish is recommended fluoride for sensitivity as is switching to a sensitivity toothpaste while going through the procedure.29

Case Scenario 2: Periodontal Disease –Smoker
Your patient, William Bagley shows up after 5 years of not seeing a dentist or hygienist. His chief complaint is that his teeth have gotten very brown and wants a whiter smile.  He admits he hasn’t been taking very good care of his teeth because he has been so busy with the construction company that he owns. He wants you to “clean them up”  today and is curious about whitening his teeth and his available options.
You review his health history where he reveals he is a smoker and has no allergies or history of tooth sensitivity. When you ask further questions about the stain you learn he  drinks 2-3 cups of coffee a day and his home care habits consist of using a manual toothbrush in the morning with “whatever toothpaste my wife buys.” He also indicates he  has tried to stop smoking but has relapsed. Upon completing an oral assessment, you notice very inflamed tissue with generalized bleeding on probing with pocket depths of  4-5 mm and slight recession throughout his mouth. Radiographs reveal calculus, which is confirmed through exploring. The brown stain he is concerned about is primarily on  lingual and interproximal surfaces. No caries are detected and all previous restorations are in good condition. After all assessments, you decide the patient will need scaling  and root planing (SRP) treatment, which will take two-three appointments. You give Mr. Bagley a hand mirror so he can see the condition of his mouth and show him  his radiographs pointing out the calculus. Next you explain the SRP procedure, stressing the importance of regaining and maintaining a state of health.
You discuss that the brown stain is extrinsic – meaning the SRP will help remove that surface stain and will help address his concern with wanting whiter teeth. You explain  that after the SRP treatment, and he regains health, you will be happy to discuss other whitening options if he still feels he would like his teeth to be whiter.

You educate the patient on proper homecare habits including recommending an electric oscillating rotating toothbrush and stannous fluoride toothpaste for his gingival  condition and tooth whitening. Use of interdental aides, such as a proxy or interdental brush are stressed since the papilla does not fill the embrasure space in most areas.  After having him demonstrate these homecare procedures and suggest he do them twice a day. This, along with counseling him on smoking cessation and regular  maintenance appointments should address his periodontal condition and reduce the amount of staining.
Case Scenario 3: Child in Mixed Dentition
Mrs. Shin brings her 9-year-old daughter, Sally, in for her examination and prophy appointment at 9 am. She tells you that she is concerned that Sally’s permanent teeth are  coming in really yellow and asks if they should be bleached. You explain that it is natural for permanent teeth to appear more yellow due to the differences in deciduous and permanent teeth. Once her permanent teeth have all erupted, they will not appear so yellow since there is no longer a contrast between them and the whiter/blue hue of her  primary teeth. The mother admits that the color difference does not bother Sally, but it is something that Mrs. Shin notices.

You strongly discourage them from pursuing bleaching treatment for a mixed dentition and discuss the guidelines from both the ADA and AAPD (American Association of  Pediatric Dentistry), which do not recommend tooth whitening/bleaching for children and teenagers before the age of 14. 3,10
If Sally is unhappy with the color of her teeth after her permanent dentition has fully erupted, you can revisit options, which may be very different than what exists today. Mrs.  Shin should know that while Sally is under the age of 18 close supervision of the chosen procedure will be extremely important to ensure proper use and compliance,  and to understand and minimize any potential adverse reactions.

Conclusion

As consumers demand easy options for whiter teeth, innovative products and trends will be available to meet those demands. Dental professionals must keep up with these  trends and provide valuable evidence-based health insights to patients for safe and effective use of these products. Current evidence suggests that all whitening options can be  effective in ideal candidates, while some will experience transient tooth sensitivity and gingival irritation, the most common side effects of bleaching. 5,14,21,24
To minimize these effects, 10% CP is recommended since it can achieve the same results as higher concentration products, although it may take longer to reach those results. 21
The scientific evidence, dental professional expertise and patient preferences should be taken into account when determining the best options for each individual.

Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please go to: www.dentalcare.com/en-us/ce- courses/ce491/test

1. Bleaching of the teeth is a form of whitening, however, not all whitening is performed by bleaching.
   A. True
   B. False

2. The active ingredient found in bleaching agents is ___.
   A. Carbamide peroxide
   B. Hydrogen peroxide
   C. Prophy paste
   D. Toothpaste
   E. Urea

3. Extrinsic stains can only be lightened by the use of chemical means in a bleaching agent.
   A. True
   B. False

4. All of the following can cause extrinsic staining EXCEPT one, which is the exception?
   A. Blueberries
   B. Coffee
   C. Red wine
   D. Chromogenic bacteria
   E. Tetracycline

5. Which of the following extrinsic stains should not be scaled?
   A. Black
   B. Brown
   C. Green
   D. Orange
   E. Red-Black

6. Which of the following is NOT necessary to review to determine if an individual is a candidate for whitening their teeth?
   A. Full oral examination
   B. Medical history
   C. History of tooth sensitivity
   D. Signs of potential infections or oral disease
   E. All are necessary to review.

7. Which of the following is NOT a contraindication for bleaching?
   A. Able to manage potential side effects
   B. Active caries or periodontal disease
   C. Current tooth sensitivity
   D. A mixed dentition
   E. Unable to follow directions

8. Typically, in-office bleaching is performed using ___.
   A. 35% carbamide peroxide
   B. 15% hydrogen peroxide and a light source
   C. 35% hydrogen peroxide
   D. 15% carbamide perioxide

9. Which of the following statements about in-office bleaching is FALSE?
   A. In-office bleaching is the quickest way to get results.
   B. In-office bleaching may require the use of take-home trays or multiple visits to accomplish desired results.
   C. Isolation techniques are necessary to protect gingival tissue from bleaching gel.
   D. Using a light source in conjunction with in-office bleaching increases the effectiveness of the whitening process.

10. Dental offices dispense what kinds of take-home bleaching options?
    A. Custom-fitted take-home trays
    B. Daily use whitening mouthrinses
    C. Flexible polyethylene whitening strips
    D. A and C
    E. A, B, and C

11. All of the following are true for OTC customer purchased bleaching products EXCEPT one, which is the exception?
    A. They are an expensive option for bleaching.
    B. Individuals with crowded teeth may see poor results.
    C. OTC trays are not custom fitted.
    D. Individuals must be compliant to achieve desired results.
    E. There is a lack of professional supervision.

12. The best option for bleaching is ___.
    A. in-office because it provides the quickest results
    B. OTC because it is convenient for individuals to purchase and use
    C. there is no “one best option” as different individuals have different needs
    D. professionally dispensed custom-take home trays because they are safe and effective

13. The most common side effect(s) of bleaching is/are ___.
    A. Nausea
    B. Gingival irritation
    C. Sensitivity
    D. B and C
    E. A, B and C

14. Natural, peroxide-free bleaching alternatives whiten just as well as traditional, peroxide-based products.
    Addition of natural agents to traditional methods may improve bleaching results.
    A. Both statements are True
    B. Both statements are False
    C. First statement is True, second statement is False
    D. First statement is False, second statement is True

15. All of the following can contribute to whether one experiences sensitivity from bleaching EXCEPT one, which is the exception?
    A. An individual’s dental history indicating sensitive teeth
    B. Higher concentrations of bleaching agent
    C. Longer contact time of bleach on tooth
    D. Misuse of the bleaching product
    E. All of the above.

16. All of the following intervention(s) can help minimize or prevent tooth sensitivity EXCEPT one, which is the exception?
    A. Fluoride vanish application prior to bleaching
    B. Using toothpastes containing stannous fluoride or potassium nitrate
    C. Use lower concentrations of bleach
    D. All of the above.

17. All of the following can help prevent or minimize gingival irritation EXCEPT one, which is the exception?
    A. Using custom trays with pre-measured gel
    B. Using isolation techniques during in-office bleaching
    C. Using OTC trays
    D. Wearing custom-fitted trays as prescribed
    E. None of the above.

18. The ADA Seal of Acceptance program allows dental professionals to confidently recommend products that have earned the Seal. The first OTC bleaching product to earn the Seal was ___.
    A. Colgate Optic White Toothpaste
    B. Crest 3D Whitestrips Glamorous White
    C. Crest 3D Classic Whitestrips Vivid
    D. Crest Whitestrips Supreme
    E. None of the above.

19. Denice Hartwell comes into your office 2 weeks after her husband Jim. She will be attending Jim’s high school reunion with him next weekend and mentions how great his teeth are lightening up. She drinks green tea daily and feels that her teeth are yellowing too. She wants to know what the best option for her might be given her time frame. She has no history of sensitivity and started using a sensitive toothpaste when Jim did. She has never tried whitening before.
    A. She should pick up a box of OTC Whitestrips on her way home since she has never bleached before to try it out first.
    B. She likes how her husband’s teeth have whitened so she should have custom trays made and get the same bleach he received (10% CP).
    C. She only has one week to whiten her teeth so she should use a higher concentration of CP or HP in her custom trays to speed up the whitening effects.
    D. Since she only has one week to whiten her teeth, professionally applied in- office bleaching is her best option.

20. It has been one year since you have completed SRP for William and he has been seeing you faithfully every 3 months for periodontal maintenance. He has been very  diligent with his home care and has been keeping the surface staining to a minimum, especially since he has quit smoking. He also has not had any further gingival  recession. At his perio maintenance visit today he mentioned he still would like to discuss whitening options. Since he has done so well with his homecare and is in a  better state of health you are happy to discuss his options. He mentioned he is concerned about the cost but does want to get significant results. Which of the following  would be viable options for William?
    A. Since William has slight recession but no sensitivity, it may be best to have him use takehome trays with 10% CP gel.
    B. William wants to see significant results, therefore in-office bleaching would be a good option.
    C. William wants to save money therefore you could recommend Crest Whitestrips and advise to ensure that the bleach is not covering the recessed areas when possible.
    D. A and C

21. Annie Walsh recently learned she is pregnant and will be in her cousin’s wedding in 4 months. She wants to know if she can bleach her teeth before the wedding since she will be in photos and hasn’t bleached them in a few years. Upon completing her oral health assessment, you notice she has slight generalized gingivitis which is  commonly seen during pregnancy and no surface stains. What do you recommend for Annie?
    A. You tell her that she doesn’t have any stain so there is no need to bleach, she should be happy with the color of her teeth.
    B. You suggest 10% CP in custom trays since it is the lowest concentration and least chance for side effects.
    C. You tell her that she should have an in-office bleaching treatment right before the wedding since she will be monitored by dental professionals.
    D. You advise her that it is not wise to bleach her teeth while she is pregnant since there is no research on the topic and it is better to not take risks.

References

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2. American Academy of Cosmetic Dentistry. Whitening survey. 2012 [cited 2019 Feb 20]. Accessed September 2, 2022.

3. American Dental Association. ADA Council on Scientific Affairs. Tooth whitening/bleaching: treatment considerations for dentists and their patients. 2009 Sept  [updated 2010 Nov; cited 2019 Feb 13]. Accessed September 11, 2022.

4. Kugel G, Ferreira S. The Art and Science of Tooth Whitening. Inside Dentistry. 2006 Sep;2(7).
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5. Eachempati P, Kumbargere Nagraj S, Kiran Kumar Krishanappa S, et al. Home-based chemicallyinduced whitening (bleaching) of teeth in adults. Cochrane Database  Syst Rev. 2018 Dec 18;12:CD006202. doi: 10.1002/14651858.CD006202.pub2.

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7. Alqahtani MQ. Tooth-bleaching procedures and their controversial effects: A literature review. Saudi Dent J. 2014 Apr;26(2):33-46. doi: 10.1016/j.sdentj.2014.02.002.  Epub 2014 Mar 12. Accessed September 2, 2022

8. Darby ML, Walsh MM. Stain management and tooth whitening. Dental hygiene: theory and practice, 4th ed. Darby ML (Ed), Walsh MM (Ed). St. Louis, MO.  Saunders/Elsevier Publishing. 2015:516-33.

9. Goldberg M, Grootveld M, Lynch E. Undesirable and adverse effects of tooth-whitening products: a review. Clin Oral Investig. 2010 Feb;14(1):1-10. doi:  10.1007/s00784-009-0302-4. Epub 2009 Jun 20.Accessed September 2, 2022

10. American Academy of Pediatric Dentistry (AAPD). Policy on the Use of Dental Bleaching for Child and Adolescent Patients. Rev 2019. Accessed September 2, 2022.

11. Curson MEJ, Duggal MS. Structure of teeth. Dental disease. Encyclopedia of Food Sciences and Nutrition, 2nd ed. Boston, MA. Elsevier. 2003:1743-6.

12. da Costa JB, McPharlin R, Hilton T, et al. Comparison of two at-home whitening products of similar peroxide concentration and different delivery methods. Oper Dent.  012 JulAug;37(4):333-9. doi: 10.2341/11-053-C. Epub 2012 Mar 21. Accessed September 2, 2022

13. Luque-Martinez I, Reis A, Schroeder M, et al. Comparison of efficacy of tray-delivered carbamide and hydrogen peroxide for at-home bleaching: a systematic review and  meta-analysis. Clin Oral Investig. 2016 Sep;20(7):1419-33. doi: 10.1007/s00784-016-1863-7. Epub 2016 Jun 11. Accessed September 2, 2022

14. de Geus JL, Wambier LM, Kossatz S, et al. At-home vs In-office Bleaching: A Systematic Review and Meta-analysis. Oper Dent. 2016 Jul-Aug;41(4):341-56. doi:  10.2341/15-287-LIT. Epub 2016 Apr

15. Accessed September 2, 2022

16. Cordeiro D, Toda C, Hanan S, et al. Clinical Evaluation of Different Delivery Methods of At-Home Bleaching Gels Composed of 10% Hydrogen Peroxide. Oper Dent.  2019 Jan/Feb;44(1):13-23. doi: 10.2341/17-174-C. Epub 2018 Aug 24. Accessed September 2, 2022

17. Sagel PA, Landrigan WF. A new approach to strip-based tooth whitening: 14% hydrogen peroxide delivered via controlled low dose. Compend Contin Educ Dent. 2004  Aug;25(8 Suppl 2):9-13. Accessed September 2, 2022

18. de Geus JL, Wambier LM, Boing TF, et al. At-home Bleaching With 10% vs More Concentrated Carbamide Peroxide Gels: A Systematic Review and Meta-analysis. Oper  Dent. 2018 Jul/ Aug;43(4):E210-E222. doi: 10.2341/17-222-L. September 2, 2022.

19.  da Rosa G, Maran BM, Schmitt VL, et al. Effectiveness of Whitening Strips Use Compared With Supervised Dental Bleaching: A Systematic Review and Meta-analysis.  Oper Dent. 2020 Nov 1;45(6):E289-E307. doi: 10.2341/19-160-L.

20. Pontes M, Gomes J, Lemos C, et al. Effect of Bleaching Gel Concentration on Tooth Color and

About the Authors
Lesley McGovern Kupiec, RDH, MSDH
Lesley has over a decade of experience as a registered dental hygienist. In addition to working part-time in clinical practice, she currently is an educator and participates in  research with The Breathe Institute, Los Angeles. She completed her undergraduate education in Massachusetts at both UMass, Amherst (BS, Sport Management) and  Middlesex Community College (AS, Dental Hygiene). In 2014, Lesley graduated from the University of Southern California with her MSDH. Lesley continues to further her  education in the area of orofacial myology focusing on health promotion and prevention from a functional approach, working collaboratively with other dedicated medical professionals. Lesley is a member of the American Academy of Physiological Medicine & Dentistry, International Association of Orofacial Myology and has held board  positions for the Los Angeles Dental Hygienists’ Society, Academy for Sports Dentistry and the National Center for Dental Hygiene Research & Practice.
Email: lesleyann411@gmail.com

Jane L. Forrest, EdD, BSDH
Dr. Forrest is a Professor of Clinical Dentistry and Chair of the Behavioral Science Section in the Division of Dental Public Health & Pediatric Dentistry, at the Ostrow  School of Dentistry of USC, Los Angeles, CA. She also is the Director of the National Center for Dental Hygiene Research and Practice. Dr. Forrest is an internationally  recognized author and presenter on Evidence- Based Decision Making (EBDM), receiving the 2017ADA/AADR EBD Accomplished Faculty Award. Dr. Forrest is the lead  co-author on the book, EBDM in Action: Developing Competence in EB Practice and its companion, the Faculty Toolkit. She also has co-authored chapters on EBDM in  Clinical Periodontology and Dental Hygiene Theory and Practice, and several article series on “how to” build skills in finding scientific evidence and apply it to decisions in clinical practice. Dr. Forrest has received federal funding for several grants including one to prepare faculty on how to integrate an evidence-based approach into curriculum.
Email: janeforrest@me.com or jforrest@usc.edu

References

• What to Know About Whitening - Dentalcare Course | Dentalcare
• What to Know About Whitening - Dentalcare Course | Dentalcare

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