The Right Way To White
Dentists Discuss Brightening Effect
By Marla Hinkle
Bright eyes and white teeth are signs of vitality. But what if the teeth are so bright you have to wear shades? Dentists have said natural looking teeth should generally match or be no brighter than the whites of a person's eye. If the so called "Hollywood Smiles" of even and blindingly bright teeth are any indication, the rest of us might be left to become slaves to bleaching techniques. Fortunately, most people do not desire blazing white choppers. This look is probably better left to celebrities whose mission is to stand out in a crowd, many dentists agree.
The degree of tooth shading is left up to his patients, said Dr. Ken Berley, a Rogers-based dentist. "If whitening is what a patient wants, then we can do it, whether it's bleaching veneers or whiter teeth," Berley said. Of course, there are times when the doctor doesn't agree. One patient wanted a more natural look and chose three shades darker than the brightest shade Berley offered. The doctor thought it was a little dark, but that's what the patient wanted. Another patient with a dark complexion chose a shade Berley said he believed was too bright, describing her teeth as "neon white." "There is no ideal shade of white; it depends on a person's complexion and hair color," he said. A dark-haired very tan young woman or man will have teeth that will naturally appear brighter than a person with fair hair and complexion. Blacks, for example, require a brighter shade because their gum tissue and skin is darker, and the teeth appear brighter. "Shading is relative to a person's background," he said.
Age is also a factor in determining how bright a person should bleach his teeth. Teeth naturally become darker in the aging process. For example, Berley recently finished a case on a 70-year-old woman. He explained that her crowns looked bad, so they discussed a correct shade. Age appropriateness in whitening techniques is something many dentists are beginning to address, he said. If a dentist makes someone "neon white" at age 40, using good techniques that last a long time, what is that person going to look like at 65, Berley said. Teeth yellow as they age, due to the enamel wearing thinner over several years of brushing. The dentine, the yellow part of the tooth, starts to show through.
Our society is more affluent than that of previous generations, and doesn't have to endure the natural aging process, he said. Whitening is increasing in the United States, Berley said, noting that most people from Europe and South America are not as interested in whitening. And Northwest Arkansas residents are not bleaching junkies. Berley said 50 percent of his patients select a more natural smile.
So how white is too white? Berley said 15 years ago, he wouldn't have done a cosmetic case in Hollywood white or "toilet bowl white," but now, not a month passes that patients do not request this, he said. This extreme bleaching is fine as long as that's what a patient wants, he said. But off-the-charts bright does have some pitfalls. Consider texture. If veneering material is not given texture, the teeth can end up looking like pieces of shiny chicklet gum," writes Rebecca W. Smith and faculty in "The Columbia University School of Dental and Oral Surgery's Guide to Family Dental Care ( W.W. Norton & Co.). She writes, "Bleaching is done to lighten teeth. It will not give them the 'Hollywood' white. If this is what you want, bonding or veneering, alone or in conjunction with bleaching, will be a better alternative." "Some people have extremely white and very prominent restored teeth that do not fit the lips and rest of the face," said Dr. Robert Hodous of The Dental Spa in Fayetteville.
"I don't have a problem with bleaching as a rule, unless the teeth are so white that they are almost bluish and fluoresce. I want to blend the teeth to fit a person's facial structure. A different shape or shade doesn't fit on some skin tones and facial forms," Hodous said.
If patients have teeth that are gray, they will not whiten. Natural teeth will whiten, he said, but existing restorations like crowns will appear darker.
Dr. Berley said he hasn't seen a case where his staff didn't see fairly satisfactory results. But he does admit that some shades of white are easier to achieve than others. Tetracycline stains usually take longer, he said. Other stain culprits are tobacco, coffee, tea, red wine, colas, illness and genetics.
Bright Smile Styles
There are no real negatives to bleaching, except for teeth sensitivity," Berley said. One of the most effective methods is in-office bleaching using the popular Zoom! technique, a light activated gel system. Zoom! offers dramatic results in a short period of time, Berley said. "Many times we will use this to jump start a bleaching case, like a young lady getting married in a week, who really doesn't have time to take home a brightening tray." The tray technique is not as speedy but is more controllable in that a patient determines how white he or she wants to bleach, he said.
Most people do not understand the difference between teeth shades and the fact that not all of their teeth are the same shade, Berley said. "You have the centrals, the two front teeth, and front laterals, which are half a shade darker. The eye teeth are a shade and a half darker. So there's not one primary shade. You are going to carry a natural progression of shade throughout your mouth. So most dentists who are really exacting in their work won't make all the teeth the same shade if you are trying to achieve a truly natural look." Berley uses the da Vinci Dental Studios in California as seen in "Extreme Makeover" and "The Swan." The results, he said, are truly remarkable and very "life-like." Dr. Hodous offers a Luma Arch whitening laser and take-home treatments. He is not big fan of over-the-counter treatments like Crest White Strips. "The strips require a lot of work and take so much longer, about six months to a year. Ultimately, people spend more money, time and energy with that type of product than a laser. Most people want to expedite the whole process, get it done and get out," he said.
Patients are required to restrict their diets of dark foods and red wine, so once the whitening is completed, they can begin to eat normally after a week or two, Hodous said. Also, he's concerned with the safety of OTC treatments, which may be high in acidity and make teeth more porous.
Kelly Bridges, a former dental assistant and office manager based at Lowell Family Dental, said she doesn't like the strips because they are difficult to use. "Your teeth have to be straight for the strips to work, because they go straight across. If your teeth aren't straight, there are some spots that will not bleach," she said. The dental office gives patients a take-home bleaching kit that is 22 percent hydrogen peroxide with fluoride, she said.
Berley said he uses two shade guides in his practice, one is natural and one is the bleaching guide. "I like to keep on the natural shade guide ... I prefer the way shades appear in nature but that doesn't really happen a lot anymore. It's really in the eye of the beholder."
American Dental Association Issues Statement
On Safety, Effectiveness of Tooth Whitening Products
From The American Dental Association
For more than a decade, the ADA Council on Scientific Affairs has monitored the development and the increasing numbers of whitening oral hygiene products. As the market for these products grew, the association recognized a need for uniform definitions when discussing whiteners.
For example, "whitening" is any process that will make teeth appear whiter. This can be achieved in two ways. A product can bleach the tooth, which means that it actually changes the natural tooth color. Bleaching products contain peroxide(s) that help remove deep (intrinsic) and surface (extrinsic) stains. By contrast, non-bleaching whitening products contain agents that work by physical or chemical action to help remove surface stains only. Whitening products may be administered or dispensed by dentists or purchased over-the-counter (OTC) and can be categorized into two major groups:
* Peroxide-containing whiteners or bleaching agents
* Whitening toothpastes (dentifrices)
Peroxide-containing whiteners or bleaching agents
Dentist-dispensed and OTC home-use products
All of the products in this category that bear the ADA Seal of Acceptance contain 10 percent carbamide peroxide; however, participation in the program is not limited to products of this concentration. There are many whitening options available to consumers both from the dentist as well as from retail outlets. The ADA recommends that if you choose to use a bleaching product you should only do so after consultation with a dentist.
In a water-based solution, carbamide peroxide breaks down into hydrogen peroxide and urea, with hydrogen peroxide being the active bleaching agent. Other ingredients of peroxide-containing tooth whiteners may include glycerin, carbopol, sodium hydroxide and flavoring agents.
Accumulated clinical data on neutral pH 10 percent carbamide peroxide continue to support both the safety and effectiveness of this kind of tooth-whitening agent.
The most commonly observed side effects to hydrogen or carbamide peroxide are tooth sensitivity and occasional irritation of the soft tissues in the mouth (oral mucosa), particularly the gums.
Tooth sensitivity often occurs during early stages of bleaching treatment. Tissue irritation, in most cases, results from an ill-fitting tray rather than the tooth-bleaching agents. Both of these conditions usually are temporary and stop after the treatment.
Professionally applied bleach whiteners
There are many professionally applied tooth whitening bleach products. These products use hydrogen peroxide in concentrations ranging from 15 percent to 35 percent and are sometimes used together with a light or laser, which reportedly accelerates the whitening process.
Prior to application of professional products, gum tissues are isolated either with a rubber dam or a protective gel. Whereas home-use products are intended for use over a two-to-four week period, the professional procedure is usually completed in about one hour.
Currently, all of the professionally applied whiteners that have the ADA Seal contain 35 percent hydrogen peroxide, although this concentration is not a requirement of the program.
As with the 10 percent home-use carbamide peroxide bleach products, the most commonly observed side effects of professionally applied hydrogen peroxide products are temporary tooth sensitivity and occasional irritation of oral tissues. On rare occasions, irreversible tooth damage has been reported.
The ADA advises patients to consult with their dentists to determine the most appropriate treatment. This is especially important for patients with many fillings, crowns and extremely dark stains.
A thorough oral examination, performed by a licensed dentist, is essential to determine if bleaching is an appropriate course of treatment. The dentist then supervises the use of bleaching agents within the context of a comprehensive, appropriately sequenced treatment plan.
Whitening toothpastes (dentifrices) in the ADA Seal of Acceptance program contain polishing or chemical agents to improve tooth appearance by removing surface stains through gentle polishing, chemical chelation, or some other non-bleaching action. Several whitening toothpastes that are vailable OTC have received the ADA Seal of Acceptance.