Tooth Bleaching FAQs: Practical Answers to the Most Common Questions

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. Vital tooth whitening has been a component of many dental offices for decades, and yet many clinicians are still uncertain how to answer some of the frequently asked questions that their patients pose. Today, we'll be discussing topics such as safety, tooth sensitivity, and how long should you bleach for. Our guest is Dr. Miles Cone, a key opinion leader, international speaker, author, and co-owner of Nuance Dental Specialists in Portland, Maine. In addition to achieving board certification and diplomat status within his prosthodontic specialty, Dr. Cone has earned his designation as a certified dental technician. Dr. Cone, it's a pleasure to have you on Dental Talk. Hey, thank you very much for having me, Phil. Pleasure to be here. And again, I encourage our guests, our guests, our audience. I guess they're guests of the show. No, you're the guest. They're not really guests. They're the audience. Yeah, it's getting late here. I've been working here all day. It's getting late. But there are four, with this one, there are four episodes to this series on whitening. And Dr. Miles Cone is really considered arguably one of the experts on whitening in the thought leader group that goes around lecturing and writing. He has an e-book on it and he's published. He's got some incredible insights into running your practice, incorporating whitening into your practice, what it does for your patients in your practice. Episode one was tooth whitening myths, making sense of the data. Episode two is tooth whitening materials, contemporary products for outstanding results. And then the most recent one we did was marketing made simple, adding value to your clinical practice with tooth whitening. Today, as I mentioned in the introduction, We're going to be going over frequently asked questions, and Dr. Cone‘s going to share his best answers to some of these questions we all get from time to time. The first one being, how white is white enough? In other words, how do your patients know when to stop bleaching? And that's, yeah, again, this is another really good question. So oftentimes when we're bleaching patients' teeth, right, we'll do the in-office, they'll leave that same day with the custom trays, and I always like to see them um you know typically they're using the custom trays throughout two weeks at home and then from the last day i tell them from the last day that that last tube of bleach runs out you need to wait about two weeks for the for the color to stabilize a bit so say i saw them you know at the first of the month they go bleach for two weeks and then i'll see them at the first of like the next month so it'll be about a month later you know oftentimes they'll come in for like a second round of in-office bleaching you know just to really give some extra punch before we go do whatever you know if it's like an single implant or a couple of veneers or something like that and so the patients almost without fail ask me like hey dr cohen do you think my teeth are white enough is this good can we go with this and the the rule of thumb here's the general rule of thumb you know because most people are like yeah when do i tell my patients to stop bleaching like what is white enough the rule of thumb is that the teeth should generally match the sclera of the eyes um and now again this is going to be this is going to vary from patient to patient you know if you've got you know a patient that has jaundice for example their eyes are going to be yellow so that that's a little bit different or you know you'll get people from different areas of the world that will have you know almost like a little tint to the sclera of the eye you know so it's going to be a little bit different but generally speaking if you can get the teeth to match the sclera of the eye that gives a nice good overall aesthetic to the patient's general appearance. There are going to be folks, too, that are going to have intrinsically stained teeth, like tetracycline, for example. Those teeth may never, ever get as white as the eye. And that's something about managing the patient's expectations, that you just have to let them know that this is going to be a protracted treatment time for patients who have heavily stained teeth. And they might never, you know, achieve like that, like Hollywood, you know, white or whatever it is. So that's, but that's my rule of thumb is if you can get them as white as the eyes, you'll be pretty good. So let's talk about safety. We didn't talk a lot about safety in the first three episodes of this series. Although, you know, we talked about carbamide peroxide 10% versus some of the more powerful hydrogen peroxide 30 some odd percent for those quick. procedures where the person's going on TV to do an interview after your visit. So how safe overall is tooth whitening? And second, are there different risks and considerations for different concentrations? Yeah, absolutely. So, you know, how safe is teeth bleaching, right? There's a little bit of an asterisk on that, right? Because it does depend on the concentration. It does depend on the material. Anytime you're using a hydrogen peroxide, like a pure hydrogen peroxide, where there's like 6%, 15%, You know, if you're doing the in-office with the Polarapid, which is what we use, obviously you need to protect the gingiva and they, you know, SDI has like a light cured resin that you can put on the gingiva as a barrier to protect that. But, you know, for the folks that are using, again, like sometimes they're using like over-the-counter stuff or, you know, there are different concentrations that you can sell to the patients to use in their trays at home. The higher the concentration, usually it's going to indicate that you use it for less time. And the benefit of the bleach, the way that the bleach really works is it really relies on contact time, which is why for 99.9% of all of our patients, we are giving them the 10% of carbamide peroxide, which is SDI's polonite. So that's the one that I'm using almost exclusively when I take it home because I find, again, it has the least amount of sensitivity. And because there's least amount of sensitivity, there's better patient compliance. Better patient compliance means that their teeth are brighter, means the patients are happier, which means they're referring their friends to us, right? So it is technically, it tends to be very, very safe. 10% carbamide peroxide is one of the most well -studied concentrations for whitening products. And the breakdown of that 10% carbamide peroxide, I'd mentioned this earlier. um it's two it's twofold like one part is the urea and then the other part is the three percent or like 3.33 hydrogen peroxide and now that amount that small amount of hydrogen peroxide that is less than what the human body is manufacturing naturally every single day in the brain the eyes and the liver and so patients always ask me the question is like what if i swallow some of this in my tray and i i feel you know i can tell them with confidence that it's not going to matter it's not going to do any damage to you it's not going to affect you at all um and here's here's here's a little bit of homework for everybody listening um you know next time you're out at the drugstore you know go go take a look where they sell all of the toothpaste and kind of look down towards like the bottom where they've got you know some of the like organic toothpaste like the toms of manes and the things like that you know and you'll notice that there's a little box called glyoxide glyoxide originally developed you know like 1957 sometime That is a 10% carbamide peroxide, and it is safe enough to be used on infants. And I know because when my daughter was about two months old and she developed thrush, this is what the pediatrician told us. She said, go get a bottle of glyoxide, soak cotton tip applicators in there, put a couple drops in her mouth and rub it around the inside of your daughter's mouth, and that'll kill the thrush. And you can do this five, six, seven times a day. So that 10% carbamide peroxide, it's safe enough for babies so i feel very confident and comfortable giving that to my patients regardless of their age or what it is that they're trying to achieve because the results from that 10% carbamide peroxide are just phenomenal. So there's a vast difference in the concentration of hydrogen peroxide in an in-office procedure versus the 10% carbamide, ultimately getting 3.3% of hydrogen peroxide that breaks down from the carbamide. So it's just the fact that it's a longer period of time of delivery. It's a slow release that you're able to get whitening results with that low level of hydrogen peroxide. Exactly. And that's just the analogy I always give to my patients because they seem to understand this. They're like, well, wouldn't the you know, if I'm using like a 37 or 38 percent hydrogen peroxide in the office, wouldn't that get me whiter, faster? You know, and they see those results kind of like right away. But the issue is with the in office is they tend to get rebound. color will rebound you know and kind of regress back over a much shorter period of time and so again the analogy i always give to people is like think about you know if you were trying to lose weight and you went and did you know if you went and did like five or six like 100 meter sprints like all at once you'd be really out of breath you'd be really sore the next day you know what i mean compared to if you went and like like ran you know 10 miles at like a slow pace and you did that like every other day for a month you know what i mean you'd lose weight much faster you'd be in much better shape you know granted doing like the sprints makes you feel like you're doing something because you kind of hurt but but that 10 percent carbamide peroxide again it's like a it's a long sort of slow release process that just it gets people just so much brighter and you know one of the big questions i get during like webinars and uh other clinicians that i know is they say hey i haven't been having a lot of success with my in-office bleaching you know the patients are complaining that it doesn't look as white as they thought it would or they're coming back you know three four months later and they say that the color seems to have progressed and i'm like yeah that that's true and they always want to know like what's my secret you know what's the secret sauce and i tell them like the custom take-home trays with that 10 carbamide peroxide with the you know the polonite that is the secret sauce and i know a lot of people have kind of shied away from doing that because it doesn't seem i don't know maybe it's like sexy or convenient doing it in an office but That's what it is. So and when we see, you know, when we do a lot of the Miss USA contestants here in the New England area, we call it my wife and I, we call it the pageant protocol. Right. My wife's the office manager. She's the smart one of the two of us. And she she's the one that kind of came up with this. And she's like, hey, you know, she went back and looked at all of the folks that we'd seen. She's like, you know what? The ones that got the whitest and stayed, you know, white is the longest. It was all of the Miss USA contestants. And this is what we did. We did in office take home. followed by in office. And then they kept doing the at home while they were like touring the country. They had their custom made trays with them and they'd wear it, you know, the night before, two nights before they're going on stage. And so that, that's how we, that's how we really do it. And relating to safety, you know, we've talked about this in some of the podcasts of this series is tooth whitening and approved procedure for pregnant lactating mothers. I have women that come in all the time and, you know, a lot of times you can't tell if they're pregnant, you know, if they're like, a month or two months pregnant usually can't tell um so on our screening forms we always this is one of these questions you know are you pregnant or lactating and specifically on our bleaching screening forms and we've had patients ask me all the time like you know why i don't understand why does that matter and i said well it matters because according to the ada and this is on the website if you guys go to the ada website in no uncertain language The ADA recommends that clinicians do not perform tooth whitening procedures while while the woman is pregnant. There's just simply not enough studies that have been done on this to say, you know, the thought process is that, yeah, it's probably safe. But like, who wants to go with probably? You know what I mean? It's just not enough. And, you know, maybe because America is such a litigious society. I back off. I don't even touch that. So I tell them, if you are pregnant, and even if you're lactating, I'm going to hold off on this because I just don't want to take the risk. And there's just not enough literature to support this. And anybody who's been listening to any of my other podcasts, you know that everything that I try to do, I try to make it evidence-based. I try to have it supported by the peer-reviewed literature. And this is one of those topics where it's just not supported. You're not going to be able to find any literature that says, that it's okay to do bleaching while while the um while the woman is pregnant but there's no we avoid right but there's no literature to say the contrary right that it's dangerous exactly and that's yes exactly and it's kind of like that great all right well there's nothing that says you can't you know what i mean but it's like okay so yeah so for me i'm just like i'm just gonna say yeah well i mean i guess the only literature that says not to is like the ada's recommendation and as our you know, umbrella, you know, governing body, like I'm going to follow their recommendations not to do that while they're pregnant. So let's wrap up this podcast with tooth sensitivity. What are your thoughts about patients complaining of tooth sensitivity during or after a bleaching? It's not too common, right? Unless I guess you're using the real extreme methods. And I don't use the word extreme as if it's a negative thing. It's just compared to the... more passive at home treatment like polonite. How do you manage to sensitivity when you do run into that? Every time you mention a question, I'm like, man, that's a really good question. That's like probably one of the most common questions. This might actually be the most common question, you know, and my, the folks that work at my office that are answering the phones, this is one of the ones that they have to feel the most. And so we've come up with, and again, we've. thrown a lot of pasta at the walls, trying to figure stuff out. And what we've come up with now at the very end, the way that we manage tooth sensitivity prior to patients coming in, like when they come into the office, we will recommend that they take a thousand milligrams of Tylenol. So that's like two 500 milligram tabs of Tylenol, 800 milligrams of Advil. So that's four of the 200 milligram Advil tabs. They do that together. same time, and they put that back with a cup of coffee or anything that has caffeine in it. And the caffeine will amplify the effect of those NSAIDs, right? So that Tylenol Advil sort of cocktail mixed with little caffeine, that has pain relieving effects that are almost at the same level of narcotics. So it is really, really potent stuff. They can take that up to three times a day without any issues. And I know a lot of people out there are like, dude, you can't take Tylenol Advil at the same time. This was like a long held belief from like the days of Reader's Digest back in the 70s. There was like some, you know, article that came out that somebody died because they took Tylenol Advil at the same time. And that has been pervasive in our in our culture for so long. And only in places like Australia and the UK could you get a pill that was, you know, a medication that was both of those combined. advil 2 and it's actually that it's ibuprofen and acetaminophen combined in in one so that's what we do oftentimes but then you know that's what we do when we're doing the in office which is it is a little bit more extreme it can tend to be a little bit more painful you know to sensitivity for in office is more frequent than it is i think when patients are doing the custom bleaching trays at home and when they are doing the bleaching trays at home we always give them potassium nitrate and sdi has you know this really great product that they called soothe and it's uh you know it's like a i think i believe it's like five percent potassium nitrate and potassium nitrate that's the same you know um that's the same active ingredient that's in like no sensodyne colgate uh sensitive you know any of these products that have some sort of sensitivity you know sensitive relief you know pain discomfort whatever in there that's what i use so they can use that soothe and it comes in a little tube just like the bleach does so in lieu of using that bleach you know they take a day off if their teeth are feeling like a little a little tender they inject some of that soothe right into their custom bleaching tray where for about 20 minutes and the soothe i mean it does just that there's no like guessing about what the what the effects of this uh potassium nitrate are, the SDI is put out, it soothes the teeth and it makes them feel, makes them feel quite nice. So if a patient were not to use this concoction or this cocktail that you talked about, and they decided to go in and just do the procedure, what's the timeframe for discomfort in an in -office procedure? And how often would that occur? That's a fantastic question. So when we were first starting out, you know, we would do these procedures and this is, I don't want to sound sexist at all, but I will tell you this. Men could not tolerate the procedure. They could not sit through the whole thing. And so, and let me just tell you this too. Since when we first started the formula, we were using a different bleaching product. I think we were using Pola Office, which was a similar product, but the recommendation was to use it for longer. And so we'd have the patient sit there. for like you know 45 minutes or so with this product on so the men if they didn't take this they'd get to about 25 30 minutes before a bead of sweat would start forming on their brow women i don't know maybe they didn't maybe they didn't experience any sensitivity or they would suffer you know they would suffer for beauty yeah yeah they would suffer quietly for beauty so they would make it through and so the only complaints i ever got i'd say like nine out of ten of them you know oh my teeth are tender was from guys that would come in. And like I said, when we were doing this for like 45 minutes, you know, at about two thirds of the way through, they were like, doc, I don't know if I'm going to make it. And so that was why it was so great. You know, when, when the new kind of recommendations came out with, with the pole, with STI's Polarapid for like 24 minutes, it's like, oh, even I can sit through that because I'm a baby too. So I can sit through 24 minutes. Yeah. Really appreciate your time, Dr. Cone. Fantastic stuff. We. Definitely want to have you again on Viva Learning to do podcasts. Yeah. And we could talk about prosthodontics as well. I know you're a prosthodontist and you're actually a certified ceramist. Certified dental technician. Yeah, I dabble in ceramics, mostly in dentures. But yeah, I do a lot of stuff that people might not know about. So yeah, but I'd be happy to come on anytime. You know, I love chatting with you. You're a great host. Amazing stuff. Thank you very much, Dr. Cone. Have a great night. Thank you so much. Pleasure. Cheers.