How to whiten teeth, even underneath brackets

Written by three renowned researchers and clinicians, this article describes the use of a new dental whitening product based on hydrogen peroxide. The effect of this compound whitens dentin in multi-directional angles, reaching areas covered by brackets and making it possible to achieve teeth whitening under braces.

Patients are willing to use this whitening procedure, both in-office and at home, because they want to achieve white teeth while under orthodontic treatment.

The result is a whitening technique that also achieves a marked increase in patients’ oral hygiene habits.

The use of hydrogen peroxide as a dental whitening agent was first described by Kingsbury in 1861.

The dentists’ desire to provide fast and effective teeth whitening procedures was described by Abbot in 1918, when he introduced a wonderful and revolutionary in-office dental whitening, a 35 percent, hydrogen-peroxide concentration that, together with heat emission from a lamp, increased oxidation.¹

Drs. Haywood and Heymann described a technique for daily use in 1989 that used a low carbamide peroxide concentration to remove deeper teeth stains, which increase with patient’s age.²

Dental whitening popularity

The success of hydrogen peroxide-based teeth-whitening products have been historically accepted and validated by research.

Messages on TV, newspapers, magazines and other media have popularized dental pigments and removal of teeth stains caused by age, food, beverages with colorants, cigarettes and tea, among others. People ask for dental whitening treatments to achieve a better esthetic and improve their smile and their self-esteem, all of which are closely related to serious dental pigmentation factors.³

The successful use of H2O2 for dental whitening, using different techniques for in-office and at-home treatment, has been described by many authors.⁴

Patients under orthodontic treatment are convinced they must maintain their oral health regarding color and esthetics. Clinicians and patients understand there is the possibility of gingival irritations and dental pigmentation alterations caused by bacterial plaque accumulation around orthodontic devices, such as brackets, bands and arches, which could lead to the decalcification processes and to long-term adverse factors. These are often caused by poor oral hygiene.

Conventional home care includes tooth brushing (mechanical or manual), irrigation devices, fluoride mouth rinses, topical fluoride applications and dental floss usage. But even with all this armamentarium, there is a low motivation.⁵

The vast majority of these devices and techniques used for oral-health hygiene are not implemented by the majority of patients, and therefore, benefits and results are not really significant. We should emphasize other alternatives that, added to the described above and together with patient awareness, could help us improve oral health of patients undergoing orthodontic treatment.

Health and esthetics

Oral health and hygiene are important factors to keep in mind for patients who are being treated with orthodontic devices; excellent hygiene is associated with the need for appropriate dental esthetics during and after treatment.

Appealing to this desire for optimal esthetics, we can implement parallel treatments that will maintain optimal periodontal health and, at the same time, protect teeth by increasing teeth enamel micro-hardness and making them less decay-prone. This is possible thanks to the new dental whitening that contains fluoride and potassium nitrate ions in its formula.⁵

For these patients, we have developed a product called Opalescence TresWhite Ortho (Ultradent, Opal Orthodontics, South Jordan, Utah) that prevents decalcification because of bacterial attack, which is responsible for carious lesions, and also increases teeth enamel micro-hardness.

TresWhite Ortho comes with an entrenched external tray for home or in-office use and is easily adaptable to teeth and brackets topography. This flexible tray contains an 8 percent concentration of hydrogen peroxide, fluoride and potassium nitrate dosage.

The flexible tray containing hydrogen peroxide should be kept on the brackets for a 45-minute period to achieve adequate contact time between whitening gel, teeth and brackets. After each 45-minute daily session, the soft tray is easily removed from the mouth and discarded, and the patient removes gel remnants by brushing.

TresWhite Ortho is the first dental whitening method that works on fixed orthodontic devices and on preventing enamel demineralization.

Hydrogen peroxide’s bacterial and plaque removal and gingival tissue healing or scarring effectiveness was proved more than 35 years ago.^6,7,8,9

Bacteria such as Streptococcus mutants and Lactobacillus are responsible for enamel demineralization white spots. Both types of bacteria are anaerobic, meaning they need a dark, warm and oxygen-free environment to survive because their organisms are unable to discard or detoxify in the presence of oxygen radicals.¹⁰

Nascent oxygen hydrogen peroxide’s conversion causes tissue and oral environment oxygenation and subsequently creates an inadequate environment for bacteria growth and reproduction.

Overcoming reluctance

Many young and adult patients are reluctant to wear fixed orthodontic brackets because of their unattractive esthetic appearance. Adequate oral hygiene is more difficult to achieve when wearing these devices, and after months or years of treatment, patients’ teeth can become dark or pigmented, thus increasing patient rejection to orthodontic treatments.

The use of already medicated, adaptable and malleable trays for home or in-office treatment is an excellent and easy way to provide patients the opportunity to have sparkling white teeth during orthodontic treatment.¹¹

TresWhite Ortho’s hydrogen peroxide conversion to oxygen is highly beneficial for eliminating gingivitis because of the ability to provide extra required oxygen during high-oxygen consumption by the inflamed gingival tissues.^12,13

TresWhite Ortho whitening power has an additional and predictable benefit. Hydrogen peroxide has a low molecular weight of 32 mg/m, which allows its easy diffusion through enamel to dentin.¹²

Once it spreads to the dentin, oxygen molecules act upon the dark pigments, rotating and fragmenting them, creating a whitening effect in the dental structure.¹⁴

Hydrogen peroxide whitens poly-directionally inside the teeth, even underneath places covered by orthodontic devices such as brackets, making it possible to obtain homogeneous whitening on patients wearing orthodontic devices.¹²

Additionally, dental whitening increases the responsibility for maintaining good oral hygiene. An 18-year-old patient is more receptive to a treatment based on a dental whitening product than to brushing with fluoride toothpaste or using anti-plaque mouth rinses.

This is quite evident when removing the soft TresWhite Ortho tray, since teeth must be vigorously brushed to remove the viscous hydrogen-peroxide based whitening gel remnants.

The result is chemical and mechanical removal of filaments and bacteria from the teeth surface and brackets.

As oral-health professionals, we desperately work to increase patient’s awareness for functional, healthy and esthetic orthodontic treatments.

TresWhite Ortho is effective in removing bacteria and achieving enamel hardness, leaving patients with white, bright and sparkling teeth. But more importantly, it leaves teeth healthy and fissure-free.

This type of result must be our new maintenance and care methodology for modern orthodontic therapies.

References
1. Fassanaro TS. Bleaching teeth: History, Chemicals and Methods used for common tooth discoloration. J Esthet Dent 1992; 4: 70–78.
2. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989; 20:173–6.
3. Hein DK, Ploegger BJ, Hartup JK, et al. In-office vital tooth bleaching — what do lights add? Compend Contin Educ Dent 2003; 24(4A):340–52.
4. Haywood VB. History, safety and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. Quintessence Int. 1992; 20: 471–488.
5. Proffit WR, Fields HW Jr, Sarver DM. Contemporary Orthodontics, 4th ed. St Louis, Mo: Mosby Elsevier; 2007:66.
6. Reddy J, Salkin L. The effect of a urea peroxide rinse on dental plaque and gingivitis. J Periodontol 1976; 47:607–610.
7. Shapiro W, Kaslick R, Chasens A, Eisenberg R. The influence of urea peroxide gel on plaque, calculus and chronic gingival inflammation. J Periodontol 1973:44:636–639.
8. Fogel M, Magill J. Use of an antiseptic agent in orthodontic hygiene. Dent Survey 1971 October: 50–54.
9. Zinner D, Duany L, Chilton N. Controlled study of the clinical effectiveness of a new oxygen gel on plaque, oral debris and gingival inflammation. Pharmacol Ther Dent 1980; 1:7–15.
10. McCord JM. An enzyme-based theory of obligate anaerobiosis: the physiological function of superoxide dismutase. Proc. Nat. Acad. Sci. USA. 1971; 68:1024–1027.
11. Morgan J, et al. Orthodontics with a twist. April-May 2007. www.orthodonticproductsonline/issues/articles/2007-04_08asp.
12. Haywood V, Parker M. Nightguard vital bleaching: how safe it is? Quintessence Int 1991; 22(7):515–523.
13. Stephan RM. The effect of urea in counteracting the influence of carbohydrates on the PH of dental plaques. J Dent Res 1943: 22:63–71.
14. Sulieman M. An overview of bleaching techniques: 1. History, chemistry, safety and legal aspects. Dental Update 2004; 31:608–616.
15. Kielbassa AM. Tooth bleaching-increasing patients’ dental awareness. Quintessence Int 2006:37(9):673.

Dr. Enrique Jadad, DDS, is a specialist in oral rehabilitation and an associate professor at Cartagena and Santiago de Cali Universities in Colombia. He is also an international visiting professor at Viña del Mar University, Chile. Contact him at ejadad@gmail.com.

Dr. Jaime Montoya, DDS, is an orthodontic specialist in private practice in Barranquilla, Colombia. Contact him at jamontoya72@gmail.com.

Dr. Arana Gordillo is a professor at Santiago de Cali University and a researcher in esthetics and biomaterials who leads the BEO Research Group. Contact him at gonzalo.arana@usc.edu.co.