Tooth whitening

Tooth whiteningTooth whitening – overview
Tooth whitening has become a popular aesthetic procedure that is offered by many dental practices. The treatment has been shown to be effective although results (and long term stability of the whitening effect) may vary depending on such factors as the type of stain, age of patient, concentration of the active agent, and treatment time and frequency. It can also permanently alter the structure of teeth so you must understand the limitations imposed by the law (The Cosmetic Products Enforcement Regulations 2013), the GDC’s requirements and good practice. Products containing or releasing between 0.1% and 6% hydrogen peroxide can only be made available to a patient via treatment by a registered dental professional; they should not be made directly available to patients. These restrictions apply equally to internal tooth whitening. Applying materials and carrying out procedures designed to improve the aesthetic appearance of teeth is the practice of dentistry. Anyone who practises dentistry illegally risks being prosecuted by the GDC in the criminal courts.
Key learning points
This advice should help you to understand the legal, professional and good practice requirements of offering tooth whitening options to your patients. It explains:
• The legal limits for tooth whitening products that contain or release hydrogen peroxide
• Who can prescribe tooth whitening and who can carry out the procedure
• Which tooth whitening products are safe to use and which should be avoided
• How to report illegal practice.
Tooth whitening in practice
The regulations prohibit the use of products that contain or release more than 6% hydrogen peroxide unless it is wholly for the treatment or prevention of disease. If using these products, you should first seek advice from your indemnity provider.
Products containing or releasing between 0.1% and 6% hydrogen peroxide
These products can only be sold to dentists and made available to a patient via treatment provided by a registered dental professional; they should not be made directly available. Exposure to the product must be limited to ensure it is used only as intended in terms of frequency and duration. These products cannot be used on anyone aged under 18 years unless it is for the treatment or prevention of disease. You should seek advice from your indemnity provider, even if you believe the treatment to be in the best interests of the patient.
Products containing or releasing less than 0.1% hydrogen peroxide
These products are safe and are freely available on the market. They include mouth rinses, toothpastes and tooth whitening products.
Who can do what
Before providing tooth whitening, you must carry out an appropriate clinical examination of the patient to ensure there are no risk factors or other oral pathology concerns that would contraindicate whitening. You should also make sure that the patient understands the costs involved and the treatment risks. The GDC’s leaflet – Considering tooth whitening – what you need to know – is a useful resource. Only dentists can prescribe tooth whitening, but it can be carried out by an appropriately skilled hygienist, therapist or clinical dental technician working to your prescription. A dental nurse with the relevant additional skills can work to your prescription and take impressions for (and make) tooth-whitening trays.
The first application
For each cycle of tooth whitening, you should undertake the first application or delegate it to an appropriately qualified hygienist, therapist or clinical dental technician working under your direct supervision (that is, within the same practice premises). Thereafter, the patient can complete the tooth-whitening cycle at home. A ‘cycle’ can be taken to mean the time taken to achieve the desired results.
© BDA April 2016 Tooth Whitening Page 3
Whitening top-ups
If you provide patients with a supply of top-up gels but did not provide the initial course of whitening, you must treat this as a new cycle and undertake a clinical examination before administering the first application yourself or delegating it to an appropriately qualified DCP working to your prescription and under your direct supervision.
Which product to use
The majority of tooth whitening materials are peroxide-based which, if used properly, are safe and effective. The most commonly seen side-effects are transient tooth sensitivity and gingival irritation
Carbamide peroxide
Some tooth whitening products contain carbamide peroxide, which decomposes in an aqueous medium to release hydrogen peroxide: a bleaching gel of 10% carbamide peroxide provides about 3.5% hydrogen peroxide.
You should confirm with the manufacturer the percentage of hydrogen peroxide released to avoid exceeding the 6% limit.
Chlorine dioxide
Products based on the release of chlorine dioxide products are harmful and the associated safety issues mean they should not be used. Many of the chlorine dioxide gels ae acidic, with a pH range from 1 to 3, which can etch the tooth surface permanently. Although teeth may initially appear white, the enamel loses its lustre, feels rougher and may pick up stain more easily and become more discoloured than before the treatment. Many patients report increased sensitivity that is difficult to manage and not easy to desensitise.
Sodium perborate
Products based on sodium perborate also release hydrogen peroxide but its classification as toxic to reproduction means that these products are banned from manufacture, sale and use.
Reporting illegal practice
Tooth whitening is the practice of dentistry. This means that, regardless of the products used, it can only be offered only by registered dental professionals.