Earn
3 CE credits
This course was written for dentists,
dental hygienists, and assistants.
Supplement to PennWell Publications
Go Green, Go Online to take your course
Abstract
Utilization of tooth whitening products and services in the U.S. and globally is very strong and shows no signs of diminishing. The three primary methods of tooth whitening include in-office, take-home and over the counter whitening agents. The two major types of tooth discoloration are intrinsic and extrinsic. Extrinsic stains are easily removed during a prophylaxis. Extrinsic discoloration can become intrinsic by migrating to the interior of the tooth through pits, fissures and surface irregularities. Peroxide containing whitening agents enhance the appearance of teeth by addressing intrinsic stains. The most common side effect of whitening procedures is transient hypersensitivity. This course provides a review of tooth whitening services and agents.
Educational Objectives At the conclusion of this educational activity participants will be able to:
1. Discuss the primary responsibilities of dental professionals.
2. Describe the available tooth whitening agents and their mechanism of action.
3. Discuss the potential benefits and side effects of tooth whitening agents.
4. Describe the different types of tooth staining.
Author Profile
Author Disclosure
Publication date: July 2015
A Review of Tooth Whitening Services
A Peer-Reviewed Publication Written by
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Educational Objectives
At the conclusion of this educational activity participants will be able to:
1. Discuss the primary responsibilities of dental professionals.
2. Describe the available tooth whitening agents and their mechanism of action.
3. Discuss the potential benefits and side effects of tooth whitening agents.
4. Describe the different types of tooth staining.
Abstract
Utilization of tooth whitening products and services in the U.S. and globally is very strong and shows no signs of diminishing. The three primary methods of tooth whitening include in-of-fice, take-home and over the counter whitening agents. The two major types of tooth discoloration are intrinsic and extrinsic. Ex-trinsic stains are easily removed during a prophylaxis. ExEx-trinsic discoloration can become intrinsic by migrating to the interior of the tooth through pits, fissures and surface irregularities. Perox-ide containing whitening agents enhance the appearance of teeth by addressing intrinsic stains. The most common side effect of whitening procedures is transient hypersensitivity. This course provides a review of tooth whitening services and agents.
Introduction
Esthetic dental services have developed over a relatively short period of time and the demand for these services is very high. Recent estimates indicate that Americans are spending over 2 billion dollars annually on the various types of tooth whitening products and services available. The terms whitening and bleach-ing are used interchangeably by both the dental profession and the lay public. It may be worthwhile to emphasize to patients that bleaching does not refer to the type of bleach used in the laundry. Whitening agents are not drugs and as such, are not regulated by the Food and Drug Administration. It should be appreciated that not all patients who desire whiter teeth are good candidates. Oral and systemic contraindications preclude some patients from these services. Patient expectations should also be addressed along with the potential side effects, most notably hypersensitivity. Esthetic procedures including tooth whitening must be considered within the context of the patient’s oral and general health, which are the primary responsibilities of dentists, dental hygienists and other dental professionals. Diagnosis and management of disease is the first and most important priority of dental clinicians. It would be inappropriate to provide tooth whitening services or any other cosmetic dental procedure to a patient with periodontal disease, caries or mucosal lesions, among many others.
The ADA Position Statement on Tooth Whitening
In April 2012 the ADA Council on Scientific Affairs adopted its; “Statement on the Safety and Effectiveness of Tooth Whit-ening Products”. The summary of the statement is as follows:
“The ADA recommends that if you choose to use a bleach-ing product, you should only do so after consultation with a dentist. 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 and patient together can determine the most ap-propriate treatment. The dentist may then advise the patient and supervise the use of bleaching agents within the context of a comprehensive, appropriately sequenced treatment plan.”
Thorough Oral Exam and an Appropriately Sequenced Treatment Plan
The ADA recommends the provision of other esthetic dental services as well. Regarding porcelain veneers, the organization states; “There’s no reason to put up with gaps in your teeth, or with teeth that are stained, badly shaped or crooked. Today a veneer placed on top of your teeth can correct nature’s mistake or the results of an injury and help you have a beautiful smile.” The most impactful aspect of the ADA’s whitening position statement is that use of bleaching agents are to be undertaken within the context of an appropriately sequenced treatment plan. Appropriate sequence clearly means prioritizing patient needs, with disease and function first, and esthetic procedures provided during or after disease management and restoration of proper func-tion. The ADA also notes the need for a thorough oral examination by a licensed dentist to determine if tooth whitening treatment is appropriate for the patient. Providing veneers, porcelain crowns, tooth whitening etc. to a patient with uncontrolled periodontitis
would be similar to a physician providing Botox® injections to a
pa-tient with uncontrolled hypertension, diabetes or atherosclerosis, among others. This is obviously the reason why the ADA cautions against the use of whitening services without consideration of the patient’s oral and overall health. Failure to examine, treatment plan and address the highest priority dental needs prior to providing cosmetic procedures would be ethically questionable. In certain circumstances necessary and elective procedures can be provided simultaneously, depending on the specific dental needs. If a pa-tient has a limited number of small to moderate carious lesions and healthy gingiva, providing in-office whitening or impressions for take-home whitening can be provided when the carious lesions are treated. If a patient has xerostomia, the etiology should be deter-mined and the condition should be addressed with an antioxidant gel or an enzymatic oral rinse, among others.
Periodontal disease is a category unto itself. Gum disease is a bacterial infection, with inflammation-driven damage to the hard and soft tissue which must be controlled prior to under-taking a cosmetic treatment plan of any kind. This may take an extended period of time. The overarching reason for addressing and controlling periodontal disease, high caries rate, xerostomia or any other oral pathology or condition prior to providing es-thetic dental services is because the same problems will continue or recur after the desired cosmetic result is achieved.
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It is completely ethical to provide tooth whitening or other cosmetic procedures when undertaken in a properly sequenced treatment plan. Contributory medical conditions such as diabe-tes, chronic infections, autoimmune disorders and chronic in-flammatory conditions are addressed first. Referral to a dental specialist or physician may be necessary. The patient’s biofilm control regimen should also be thoroughly evaluated since the most common oral diseases and conditions are directly linked to the oral bacterial load. Recommendations for the appropriate biofilm control devices such as power toothbrushes, antimicro-bial rinses and interdental cleaning devices should be provided not only to facilitate optimal oral and general health, but to protect the patient’s financial investment in their appearance.
Extrinsic Stains
The superficial or extrinsic coloration of an individual’s teeth is associated with stain that accumulates on the surface of the teeth from food and beverages, which can seep into the cracks, pits and flaws in the enamel. Seepage can also occur between the enamel rods in some cases. Some individuals seem to be more susceptible to extrinsic staining due to enamel surface mor-phology, salivary proteins, diet, tobacco usage and the efficacy of the home care. High levels of extrinsic staining are caused by polyphenolic compounds found in food and beverages such as red wine, darkly brewed tea, chocolate, coffee, grapes, pome-granate, spinach and plums, among others. Superficial stain accumulation occurs as a result of the attraction between the negatively charged salivary pellicle and the positively charged food/beverage molecules. (Figures 1, 2) Extrinsic stain is sub-stantially removed by abrasives in toothpaste and prophy paste.
Figure 1. Staining from chlorhexidine rinse
Figure 2. Extrinsic stain
Intrinsic Stains
When extrinsic stains migrate below the surface they become intrinsic stains and can no longer be removed by mechanical means. Intrinsic molecules that cause discoloration are organic pigments incorporated into enamel during tooth formation. The visual effects of intrinsic tooth color are associated with the absorption and reflection of light by the enamel and dentin with the dentin playing the primary role in determining overall tooth color. The natural off-white hue of enamel is modified by the yellow/brown shades of dentin, together determining the normal color of an individual’s teeth. Discoloration can also be caused by trauma, tetracycline and a number of metabolic diseases and other systemic factors. Postnatal infections such as chicken pox, streptococcal infections and scarlet fever can result in tooth discoloration as well. With advancing age, an individual’s teeth commonly take on a generalized yellow or brown color. This occurs as a result of thinning of the enamel, thus revealing more of the darker underlying dentin. Addition-ally, over time, the dentin becomes darker from the formation of secondary dentin in response to restorations and normal physiologic processes.
Figure 3. Discoloration of central incisor from trauma
Figure 4. Discoloration from trauma
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Figure 5. Flourosis staining
Figure 6. Flourosis staining
Figure 7. Tetracycline staining
Figure 8. Tetracycline staining
Figure 9. Staining from postnatal infection
Enamel is semitranslucent and the underlying dentin color and other colored substances beneath the enamel affects the overall color of the teeth. Tooth color is caused by a variety of factors including the influence of genetics, drugs and medica-tion taken by the mother while pregnant or the child during tooth development such as tetracycline. Environmental factors such as excess fluoride intake and maternal infections also influence tooth color. An individual’s genetic makeup is the primary determinant of tooth color. Some people’s teeth have a blue-gray base color, others more yellow-brown. When it comes to tooth whitening, yellow and brown base colored teeth whiten faster than blue-gray teeth.
The color molecules are comprised of groups of atoms that are held together by bonding forces. Some of these bonding forces themselves absorb and reflect light. The absorption of light makes the object, in this case the teeth, appear darker and light reflec-tion gives the appearance of color. These absorbing and reflecting bonds are called chromophores and they are all around us. Every-thing we see, and the colors we observe and due to chromophores. Peroxide based whitening agents work by breaking the chromo-phore bonds, bringing out the natural whiteness of the teeth.
Mechanism of Action of Peroxide Tooth Whitening Agents
Intrinsic staining is removed by chemical means, primarily dif-ferent forms of peroxide. Typically used whitening agents are hydrogen peroxide or carbamide peroxide-containing whitening gels, liquids, strips etc. Carbamide peroxide is broken down into hydrogen peroxide and urea upon dissolution in water or saliva. Peroxide based bleaching products diffuse into the tooth and re-act with the color molecules. The mechanism by which peroxide compounds lightens the color of the teeth involves the chemi-cal composition of the intrinsic stain. Upon application of the
bleaching gel, hydrogen peroxide (H2O2) breaks down into H2O
and a free reactive oxygen species. These hydrogen peroxide breakdown products attach to the stained portions of the teeth which have the chromophore bonds. The free reactive oxygen species break the double chromophore bonds into single bonds. The single bonded carbon atoms produce colorless molecules bringing out the natural whiteness of the teeth. (Figure 10)
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Figure 10. Mechanism of Action: Hydrogen Peroxide (H2O2) Carbon Double Bond Free Radical Generated H2O2
Tooth Whitening Treatments
Chemical tooth whitening can be performed in-office or at home, using products dispensed in the office or over the coun-ter (OTC). Professionally provided and consumer take-home bleaching agents are supplied as pastes or gels that are used in trays, strips, rinses or paint-on liquids. The whitening agents typically used with take-home products are carbamide peroxide or hydrogen peroxide. The concentration of the whitening agent ranges between 10-35% depending on the manufacturer. The same agents are used for in-office whitening and the con-centrations can range up to 40% hydrogen peroxide. The oral tissue must be carefully isolated to prevent soft tissue irritation and ingestion. The most common method of isolation is by using paint-on or rubber dams. Protective eyewear must also be used by patients undergoing in-office bleaching, as is the case anytime a curing light is used and aerosols are created. An example of the steps involved in in-office whitening are shown in figures 11-17.
Figure 11. Application of paint-on dam for gingival protection
Figure 12. Curing dam
Figure 13. Application of whitening gel
Figure 14. Completing application of whitening gel
Figure 15. Whitening gel removal with air/water syringe after recom-mended period of time
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Figure 16. Removal of dam
Figure 17. Final results demonstrating significant whitening
Figure 18. Before and after chemically activated in-office tooth whitening.
Take home whitening involves a simple process as shown in figures 19 and 20. The patient should receive instructions to ensure safety which include whitening only for the specified period of time once per day and to avoid overfilling the trays.
Figure 19. Application of whitening gel to facial surface of tray
Figure 20. Placement of the tray in the upper arch
In-office whitening treatments provide immediate results while take-home products can take days or weeks to provide the same result. In-office whitening procedures commonly employ the use of chemically activated whitening systems, while other systems are light activated. Tooth whitening due to dehydration can occur in some cases of light activated in-office whitening. In such cases rebound can occur making the teeth look darker than they looked immediately following the whit-ening procedure, potentially leading to patient dissatisfaction. The peroxide concentration of take home bleaching agents are generally lower than in-office whitening agents. This is due to the lack of professional application and supervision with agents applied by the patient.
There are advantages and disadvantages to in-office and take-home whitening treatments, just as there are for virtually any situation with multiple options. The primary advantage of in-office whitening is the same day results. For some patients this may be the best option due to a personal or social event such as a wedding or reunion, receiving an award or starting a new job in the near future. Another consideration for many patients is cost. In-office treatment is commonly more expensive than take-home whitening. Compliance is another consideration. Patients may opt for in-office whitening, or the clinician may recommend in-office treatment if they know from past experi-ence that compliance is an issue in general. Patients who have difficulty taking all doses of prescription medication or those who have had past compliance issues with take-home whiten-ing may be good candidates for in-office treatment.
The advantages of in-office whitening are the same day results and the lack of compliance issues. The cost may be perceived to be a disadvantage by some patients. The primary advantage of take-home preparations is the lower cost. Disad-vantages of take-home treatments include the longer time frame to achieve the end results and the potential for non-compliance.
Tooth Whitening Contraindications
Patient selection is critical when tooth whitening is being considered by the patient or recommended by the clinician. Women who are pregnant or nursing should avoid all whiten-ing procedures and products. There is no research demonstrat-ing safety durdemonstrat-ing pregnancy or while nursdemonstrat-ing. Children should be carefully screened. Tooth whitening for patients below the
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age of 15 should only be provided with careful consideration. Patients in this age category should only be treated under dental professional supervision. Patients with gum disease, especially periodontitis, should defer esthetic procedures of all types, including tooth bleaching, until the disease is controlled. There is some evidence that peroxide compounds kill bacteria and may thereby be beneficial to the gingiva, but tooth whiten-ing should never be considered or cited as a viable primary or adjunctive treatment option for periodontal disease. Patients with significant restorative needs should have these addressed prior to whitening the teeth. Other contraindications may include exposed root surfaces, xerostomia or a history of hyper-sensitivity. Individuals with dental restorations involving the facial surfaces of teeth in the esthetic zone must be advised that the restorations will not respond to the whitening agents. This includes composite restorations, hybrid restorations, crowns, veneers, bridgework or any other dental restorative material. Patients should be advised that whitening procedures will only have an effect on natural tooth surfaces and that restorations may need to be replaced after whitening the teeth.
Issues Associated with Tooth Whitening
Potential side effects of tooth whitening are changes to the properties of dental restorations. There is significant variability of whitening agents including concentration, duration of con-tact and pH, among others. Some studies have shown no effects on dental restorations. Other studies have shown an increase in surface roughness and decrease in hardness of porcelain resto-rations. Other studies have shown deleterious effects to glass ionomer cements. Numerous studies have demonstrated a po-tential for changes to composite restorations. Still other studies have shown changes to color, surface hardness and roughness, staining susceptibility, microleakage and elution, in which the composite material washes out of the restorations. The large number of variables and inconsistent study results prevents de-finitive conclusions regarding the effect of whitening agents on restorations at this time. However, caution should be advised with all tooth whitening systems due to the potential negative effects on dental restorations and materials from improper use. Survey research has indicated that the most frequently re-ported issue with whitening treatment is sensitivity, followed by soft tissue irritation. Gingival, lingual, palatal or mucosal irritation is caused by exposure of the tissue to the bleaching agent. Ill-fitting or overfilled take-home trays can result in tis-sue exposure and irritation. Improperly applied paint-on dam
heat, acids, pressure and chemicals, among others, to the nerve endings in the pulp. The basis of this theory is that the fluid filled dentinal tubules are open to the oral cavity at the dentinal surface as well as within the pulp.
Figure 21. Brannstrom’s hydrodynamic theory.
Stimuli on exposed dentin cause fluid movement in tubule Fluid travels through tubule
and excites nerve
Sensitivity is subjective and transient with symptoms usu-ally disappearing in a matter of hours or a few days.
Some whitening agents will dehydrate the teeth, particularly if they are anhydrous, and this can also contribute to sensitivity. The dehydration can make the teeth appear whiter and as the tooth rehydrates in a short period of time the whiter color dissi-pates. This phenomenon can easily be mistaken for a transient, short duration whitening result, when in reality it was due to dehydration of the tooth. Rebound of whitening effect can also occur in which the pre-treatment discoloration of the teeth reappears. Hydrogen peroxide changes the color of the stain molecules, rather than actually removing them. Over time, the stained appearance can reappear.
Prior to whitening treatment, a thorough conversation with the patient especially those who experience sensitivity to temperature variation. Discussing the potential for sensitivity to patients prior to undertaking treatment will help the pa-tient make an informed decision. Thorough documentation of pre-op conversations is important as well. The manufacturers of whitening materials have addressed sensitivity by adding different compounds to the bleaching agent. These include amorphous calcium phosphate, potassium nitrate and fluoride,
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surfaces or those with generalized thermal sensitivity need to be informed that they are not candidates for tooth whitening. Patients who are allergic to peroxides must be excluded as well. Systemic contraindications include patients with asthma or other respiratory conditions, uncontrolled diabetes or cancer. Patients with restorations in the esthetic zone need to be in-formed that they may need to be redone to match the shade of the teeth after whitening. Patient’s expectations should also be discussed if the teeth have bands of discoloration or very dark teeth prior to whitening. Once it has been determined that a patient is a good candidate for whitening and all other dental needs have been addressed, a discussion of the potential side ef-fects should occur. Among the topics that must be discussed is the possibility for hypersensitivity, soft tissue inflammation or other side effects. The final shade that will be achieved cannot be guaranteed without risking patient dissatisfaction. The po-tential for rebound of the discoloration must also be mentioned, as well as the possibility of non-uniform results. Some patient’s teeth have a streaky or blotchy appearance after whitening. This usually self corrects in a short period of time. In some instances, the non-uniform results are due to dehydration which correct in a few hours or days. The need for thorough documentation cannot be overstated. The patient notes should include the essential nature of the dialogue, potential contraindications, expectations, etiology of the discoloration and the patient’s level of understanding of the potential side effects. Documen-tation should also indicate that the patient had the opportunity to ask all of their questions and they understood the answers provided. The records should be similar to an informed consent document.
Ideally at this point the patient selects in-office or take-home whitening. Prior to undertaking whitening treatment a pre-op shade must be selected, having the patient participate in the initial shade selection. For patients who select take-home whitening, they should be instructed to whiten until the desired shade is achieved, rather than for a pre-determined number of days. Appearance in general is subjective and the patient’s opinion of what constitutes an ideal result should be discussed in advance. Choosing and endpoint for treatment can provide a goal for the patient.
Conclusion
When undertaken with careful consideration and proper sequencing of treatment, whitening can have a very positive outcome for the patient. Patients who are reluctant to smile in general, in photographs, in social or business situations due to the appearance of their teeth can experience a life changing outcome from tooth whitening. There are many reasons why people whiten their teeth but the underlying motivation is the desire for a better looking smile. There are many reasons why people want to enhance their appearance including career advancement. The obvious examples include models, televi-sion and movie actors. Others include corporate executives
and public speakers. Among the reasons cited by individuals who whiten their teeth are self-esteem and confidence in social and business situations. Tooth whitening is the number one cosmetic procedure because it’s the most affordable way to significantly improve one’s appearance.
Further developments in whitening procedures and materi-als will continue in the future. Improvements in the predict-ability of the results, outcomes and reductions is side effects will benefit our patients and our practices.
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Kossatz S, et al. Tooth sensitivity and bleaching effectiveness associated with use of a calciumcontaining in-office bleaching gel. J Am Dent Assoc. 2012 Dec;143(12):e81-7.
Basting R, et al. Clinical Comparative Study ofthe Effectiveness of and Tooth Sensitivity to 10% and 20% Carbamide Peroxide Home-use and 35% and 38% Hydrogen Peroxide In-office Bleaching Materials Containing Desensitizing Agents. Oper Dent. 2012 Sep-Oct;37(5):464-73. doi: 10.2341/11-337-C. Epub 2012 May 18.
He LB, et al. The effects of light on bleaching and tooth sensitivity during in-office vital bleaching: a systematic review and meta-analysis. J Dent. 2012 Aug;40(8):644-53. doi: 10.1016/j.jdent.2012.04.010. Epub 2012 Apr 21. Dawson PF, et al. A clinical study comparing the efficacy and sensitivity of home vs combined whitening. Oper Dent. 2011 Sep-Oct;36(5):460-6. doi: 10.2341/10-159-C. Epub 2011 Aug 22). Author Profile
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Questions
Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.
1. The color of and individual’s teeth results from:
a. Intrinsic and extrinsic color molecules b. Intrinsic and interior color molecules c. Extrinsic and exterior color molecules d. Superficial stains only
2. Which of the following can increase the discoloration of teeth?
a. Trauma
b. Surface irregularities c. Enamel pits and fissures d. All of the above
3. The American Dental Association’s position on tooth whitening states: a. Tooth whitening is appropriate for everyone with
dark teeth
b. Tooth whitening can be undertaken after a thorough exam
c. Tooth whitening can be undertaken as part of a properly sequenced treatment plan
d. Both b and c
4. The most common side effects of tooth whitening are:
a. Sensitivity and periodontitis b. Sensitivity and gingivitis c. Sensitivity and soft tissue irritation d. Sensitivity and caries
5. Causes of intrinsic staining include; a. Frequent consumption of darkly brewed tea b. Trauma
c. Medications d. Both b and c
6. Tooth sensitivity association whitening is: a. Permanent
b. Always severe c. Transient d. None of the above
7. Contraindications to tooth whitening include all of the following except: a. Active periodontal disease
b. Orthodontic treatment c. 18 years of age d. Pregnancy
8. Which of the following is true regarding tooth coloration?
a. Intrinsic stains can become extrinsic stains b. Extrinsic stains can become intrinsic stains c. Extrinsic stains are the result of organic pigments
incorporation during tooth formation d. None of the above
9. Which of the following is true regarding the FDA’s position on tooth whitening procedures?
a. FDA approves whitening procedures b. FDA regulates whitening procedures c. FDA has not taken a position on whitening
procedures d. None of the above
10. Which of the following is generated by H2O2?
a. Free radicals b. H2O
c. Both a and b d. None of the above
11. Which of the H2O2 breakdown products
breaks carbon to carbon double bonds? a. H2O
b. The unpaired oxygen free radical c. Both a and b
d. None of the above
12. Carbamide peroxide breaks down into: a. Hydrogen peroxide and urea
b. Hydrogen peroxide and H2O
c. Hydrogen peroxide and oxygen d. Free radicals
13. Which of the following is true regarding managing tooth patient expectations with tooth whitening procedures?
a. Discussions should be undertaken during the treatment
b. Potential side effects should be addressed when they occur
c. The final shade of the teeth can be guaranteed prior to whitening
d. None of the above
14. Brannstrom’s hydrodynamic theory indicates;
a. Static fluid in the dentinal tubules increases sensitivity
b. Movement of particles in the dentinal tubules increases sensitivity
c. Movement of fluid in the enamel increases sensitivity
d. None of the above
15. Which of the following conditions may be contraindications for tooth whitening? a. Xerostomia
b. Previous thermal sensitivity c. Compliance issues d. All of the above
16. Which of the following is true regarding advantages and disadvantages of in-office and take-home tooth whitening? a. The primary advantage of take-home whitening is
the same day results
b. The primary advantage of in-office whitening is the same day results
c. The primary disadvantage of take-home whitening is the cost
d. The primary disadvantage of in-office whitening is compliance
17. Materials used to reduce sensitivity include all of the following except;
a. Amorphous calcium phosphate b. Potassium nitrate
c. Amorphous calcium nitrate d. Variable light intensity
18. Gingival, lingual, palatal or mucosal irritation is caused by:
a. Exposure of the tissue to the bleaching agent b. Ill-fitting or overfilled take-home trays c. Improperly applied paint-on dam d. All of the above
19. Studies have shown changes in composite restorations after tooth whitening including:
a. Elution
b. Improved surface hardness c. Reduced surface roughness d. Increased longevity of the restoration
20. Patient documentation should include: a. The essential nature of the dialogue between
clinician and patient b. Potential contraindications c. Patient expectations d. All of the above
21. Consumption of foods rich in which of the following increases extrinsic staining? a. Alkaline compounds
b. Polyphenols c. Acidic compounds d. All of the above
22. It is ethical to provide tooth whitening services:
a. When undertaken as part of a properly sequenced treatment plan
b. Without a radiographic examination c. Without a clinical examination d. All of the above
23. Which of the following is correct regarding tooth whitening for adolescent patients? a. Careful screening is required
b. Patients under 15 should only be treated after careful consideration
c. Professionally supervision is critical d. All of the above
24. In-office whitening procedures typically use H2O2 concentrations of:
a. 20-30% b. 40-50% c. 25-35% d. 35-45%
25. Breaking down the carbon to carbon double bonds in stain molecules: a. Removes the stain
b. Lightens the stain c. Has no effect on the stain d. Darkens the stain
26. Setting patient expectations prior to tooth whitening includes all of the following except: a. Side effect development
b. Non-uniform initial results c. Improved periodontal condition d. Replacement of restorations
27. Soft tissue irritation from tooth whitening may be caused by:
a. Ill-fitting trayss b. Improperly applied barriers c. Peroxide whitening agents d. All of the above
28. Peroxide whitening agents work by: a. Making single bonds into double bonds b. Breaking double bonds into single bonds c. Making double bonds into triple bonds d. Breaking triple bonds into single bonds 29. Which of the following affects color
perception? a. Absorption of light b. Light reflection c. Dentin d. All of the above
30. Isolation during in-office whitening include all of the following except: a. Vinyl dam
b. Paint-on dam c. Tofflemire band d. Lip and cheek retractors
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ANSWER SHEET
A Review of Tooth Whitening Services
Name: Title: Specialty:
Address: E-mail:
City: State: ZIP: Country:
Telephone: Home ( ) Office ( )
Lic. Renewal Date: AGD Member ID:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
Educational Objectives
1. Discuss the primary responsibilities of dental professionals.
2. Describe the available tooth whitening agents and their mechanism of action. 3. Discuss the potential benefits and side effects of tooth whitening agents. 4. Describe the different types of tooth staining.
Course Evaluation
1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No Objective #3: Yes No Objective #4: Yes No
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0
5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0
6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0
7. Was the overall administration of the course effective? 5 4 3 2 1 0
8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0
9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0
10. Do you feel that the references were adequate? Yes No
11. Would you participate in a similar program on a different topic? Yes No
12. If any of the continuing education questions were unclear or ambiguous, please list them.
________________________________________________________________ 13. Was there any subject matter you found confusing? Please describe.
_________________________________________________________________ 14. How long did it take you to complete this course?
_________________________________________________________________
For IMMEDIATE results, go to www.ineedce.com to take tests online. Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
Payment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: ______________________________ Exp. Date: _____________________
Charges on your statement will show up as PennWell
If not taking online, mail completed answer sheet to
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp. P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
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