Brightening Your Patient’s Smiles

Q. Where should dental professionals start in creating a treatment protocol for tooth staining?

A .The most important facet of treating tooth stains is prevention, which begins with educating patients on how to effectively clean their teeth at home in order to prevent staining, according to their own habits and metabolism. In our dental practice, we typically advise patients to use a power toothbrush in addition to a once-a-day site-specific rotary brush*.

Dental professionals should begin with a thorough diagnosis, reviewing any medications the patient is taking since some commonly prescribed antibiotics, such as minocycline, can cause tooth staining. I have also observed that patients taking iron supplements frequently have more surface stains. These types of drugs combine poorly with calcium and may darken the whole tooth. A study done by Bowles showed the effect high doses of vitamin C have on tooth color in rats that were given minocycline.¹ The rats ingesting vitamin C experienced less staining than those taking only the minocycline. Although a similar study has not been conducted on humans, a high dosage of vitamin C per day (2,000 units – 4,000 units) may be a good option for those who must take minocycline. However, I recommend patients check with their physicians before beginning any mega-dose vitamin C regimen.

Dental hygienists are the first line of communication with the patient, therefore, they are well-suited to delve into medication use and should warn patients about the esthetic risks of taking such medication. The dental hygienist can counsel the patient to consider alternatives if minocycline-type drugs have been prescribed. If a patient presents with severe staining in his or her normal 4- to 6-month prophylaxis schedule, the time between visits should be reduced to 3 months or even more frequently if necessary. Playing detective with the patient can be helpful if he or she has a great deal of staining. Most often I discover that it is a habit or food substances that is causing the staining.

THE ESTHETIC DENTAL PRACTICE

Q. What role do dental hygienists play in esthetic dentistry?

A. Dental hygienists are key members of the dental team and I believe they should play a more significant role in the diagnosis stage to help prevent esthetic problems. Possibly then, dentists could spend more time with patients reviewing conditions that are brought to their attention by dental hygienists. A good example is tooth wear.

Often patients grind down their teeth without a dental professional realizing it until the damage is severe. This can result in a patient ruining his or her smile since wearing incisal edges can produce an older looking smile.² To prevent this from happening, the hygienist must regularly examine the incisal edges for wear. Any time a dental hygienist sees the tip of a cuspid that is not sharp or rounded as it’s supposed to be, that patient needs to be warned that he or she is wearing the teeth down. This way the situation is addressed before the condition becomes an esthetic and functional concern. A properly designed and fitted bite guard can be prescribed for wearing during sleep and to remind the patient of possible grinding during the day. I recommend patients make signs that read “Lips together…teeth apart” and place them in cars, desks, or other places where they spend a great deal of time. I am always amazed at how many patients do not realize that the only time their teeth should touch is when they’re eating.

Another area where the hygienist can play an important role is by making sure the new patient is happy with his or her smile. Unfortunately, I see many botched esthetic cases that have to be redone to please the patient both esthetically and functionally. The dental hygienist is well-positioned to open the discussion, especially if the smile can be improved.

Q. What is the most common patient population in esthetic dentistry?

A. In our practice, most patients come in after they have tried over-the-counter (OTC) bleaching products and are not satisfied with the results. Some patients don’t realize that OTC bleaching products do not work on bonded or crowded teeth. Overall, patient education and communication about patient expectations are the first steps prior to treatment.

Additionally, some patients experienced tooth decay as children and now have both composite and acrylic fillings that have discolored the teeth. Although the fillings can be replaced with tooth-colored composite resin, if the enamel has either stained micro-cracks or too much translucency, then porcelain veneers may be a better choice.

Q. How do you treat patients with discoloration caused by fillings?

A. Tooth stains can be caused by defective amalgam fillings that are placed on the backs of front teeth; these cases are usually not good candidates for bleaching. The dark fillings can be taken out and replaced with a lighter shade composite resin and then the teeth can be bleached, which may improve the tooth color. The dental hygienist can play an important role in these cases. When examining the front teeth, particularly the lateral incisors, the hygienist should check for signs of lingual pitting. If present, the patient may have stains in them, but beneath the stains there may be caries. In our practice, we have found a high rate of decay in patients with lingual pitting. To ensure that we can identify this type of hidden caries and others, we use an automated caries detection device following a prophylaxis. If the LED read-out and audible instant sound indicate decay is present, I usually use air abrasion or a laser to comfortably remove the decay, then a composite is placed to restore the tooth. Otherwise, the tooth continues to decay, which can further influence the tooth color and possibly require a future endodontic procedure.

TREATMENT

Q. What types of whitening treatments do you recommend?

A. I most often recommend in-office bleaching combined with an at-home regimen. However, before any treatment is planned, the patient’s radiographs must be examined carefully. By looking at the size of the pulps of the upper anterior teeth, we can determine the treatment plan. For instance, a patient with very large pulps is probably better off doing an at-home bleaching tray treatment—especially using a bleaching agent combined with a desensitization agent.

For patients who find OTC treatments too messy, we make a form-fitting tray and recommend using the bleach 1 to 3 hours nightly. However, I don’t recommend sleeping with it because it may irritate the gingiva. If the patient has a lot of exposed dentin, then an in-office treatment is recommended because the exposed dentin can be covered by a rubber dam substitute to protect it. If the patient has a pulp that’s not too large, I recommend an in-office treatment. We have six different systems in our office, so we can choose the one best suited for the patient, which is followed by at-home treatment for 4 weeks. The combination technique seems to provide the best results. Additionally, the patient has trays that can be used at home for touch-ups.

Some patients do not want a home component to their whitening treatment at all due to their busy schedules. They prefer to have the whole treatment completed in-office. When a photo is taken immediately after whitening, the teeth are dehydrated and will look whiter than they truly are. A photo taken 2 weeks later is more accurate. So for patients who do not want an at-home component, they need to come into the office for additional treatments to get their desired shade.

Q. What about treating more difficult types of staining?

A. Sometimes an orange stain is seen around the necks of teeth and around fillings, which can be caused by chromogenic bacteria. This type of staining is very difficult to treat because the bacteria must be eradicated. Sometimes a massive dose of antibiotics can help eliminate them. If patients are using a chlorhexidine mouthwash, a bad stain can result but it can be polished-off with more frequent prophylaxis appointments. Stannous fluoride can cause a light brown or yellowish stain in some patients, but can be polished off. For staining that does not respond to bleaching, porcelain laminates or crowning may be a better option.

REFERENCES

1. Bowles W. Protection against minocycline pigment formation by ascorbic acid. J Esthet Dent. 1998;10:182.
2. Goldstein RE. Change Your Smile. Hamilton, Ontario: BC Decker; 1997:239.

*Rota-Dent One Step^®, Pro-Dentec^®, a Zila Inc Co, Batesville, Ark

From Dimensions of Dental Hygiene. November 2007;5(11): 16, 18-19.