Are you finding that some of your patients are not achieving maximum satisfaction with their whitening treatment? Here's an insight into why this may be happening and how you can solve the problem.
If you don't know that the system Enlighten guarantees shade B1, you’ve probably been living under a rock. But that’s okay! We should probably start by stating the obvious and say that the information below was gathered over years of evaluating successful and unsuccessful cases, all treated with only the Enlighten whitening system. Now that we’ve gotten that out of the way…
What is shade B1 and what does it look like?
It is the lightest natural shade in the VITA shade guide and the dream shade for most people.
For all our curious patients, the most common shade in humans is A3. We are usually born with relatively white teeth, but as we age, they begin to accumulate stains and turn yellow due to eating and drinking habits, inconsistent oral hygiene, or various conditions.
So, how do we ensure that all patients are able to achieve that gorgeous, pearly B1 shade?
Understanding the clinical situations that make whitening cases simple, but especially difficult, is one of the cornerstones of planning a successful whitening treatment. After analyzing over 3700 Enlighten 2-week (from the previous Evo3 system) and 3-week (from the current Evo4 system) failures, we identified them into 6 types of cases, Bruxism being the most common problem. Not everyone's teeth are the same, so it's unrealistic to expect a 3-week standard to work the same for everyone.
Standard cases (cases that have not been identified as difficult) can usually achieve B1 within 3 weeks of whitening. These are cases with good oral hygiene and teeth in good overall health, with no apparent signs of disease. The recommended top-up regimen for standard cases is: While ideally maintaining attachments on the back teeth, top up with a syringe of Week 2 (16% CP) once a month for the first 6 months. Remove attachments and, for the next year, perform a nightly whitening every 2 months. In the long term, whiten one night every 6 months or as needed. As we consistently adhere to the top-up regimen over a long period, the demand is expected to gradually decrease. Patients with known sensitivity issues can be recommended the same supplementation regimen, the only modification being the use of a lower concentration of gel from Week 1 (10% CP).
Enlighten, with an impressive 21-year track record of continuous improvement, was founded by dentists and has successfully treated over 200,000 patients. Enlighten's distinction lies in its deep whitening process, which sets it apart from other brands. Ensuring B1 shade is not a coincidence; rather, it results from years of meticulous observations, case studies, and continuous product refinement based on a deep understanding of its performance.
APE BET. You heard it here first!
A little tip: you can remember the following cases with the help of the mnemonic APE BET. Here are the 6 clinical situations that make whitening difficult:
1. AGE
This has been well documented, but our analysis showed that patients over 60 years of age were most likely to need longer to achieve B1.
Recommended treatment plan (if the patient has no known sensitivity issues):
Minimum 5 weeks with the following protocol:
- Week 1 at 10% CP overnight for as long as asleep
- Week 2 at 16% CP overnight for as long as asleep
- Week 3 at 6% HP during the day for 1 hour each day
- Week 4 at 16% CP overnight for as long as asleep
- Week 5 at 16% CP overnight for as long as asleep
- If patient does have sensitivity issues, swap all overnight gel for the lower concentration, Week 1 syringe (10% CP).
2. APPROACH TO THE GINGIVAL MARGIN
Problems such as dark areas, white and brown spots, stained crack lines, and even tetracycline bandages are more difficult to address with whitening as they approach the gumline.
There are 2 main reasons for this:
- Enamel is thinnest at the gumline.
- Saliva leakage inside and gel leakage outside the tray are greater at the gingival margin.
Recommended treatment plan (if the patient has no known sensitivity issues):
Minimum 5 weeks with the following protocol:
- Week 1 at 10% CP at night, while sleeping.
- Week 2 at 16% CP at night while you sleep
- Week 3 at 6% CP during the day for 1 hour every day
- Week 4 at 16% CP at night, while you sleep
- Week 5 at 16% CP at night while you sleep.
- If the patient has sensitivity issues, change all night gel to the lower concentration, week 1 syringe (10% CP).
3. ENAMEL THICKNESS
Thinner enamel is harder to whiten. Very thin enamel is then, in turn, very difficult to whiten. The white saturation point (the point at which the tooth cannot get any whiter) is most affected by this variable than any other. This can be caused by:
- Age
- attrition
- Abrasion
- Erosion
Recommended treatment plan (if patient has no known sensitivity issues):
Minimum 5 weeks with the following protocol:
- Week 1 at 10% CP overnight, while sleeping
- Week 2 at 16% CP at night while sleeping
- Week 3 at 6% CP during the day for 1 hour every day
- Week 4 at 16% CP at night, while you sleep
- Week 5 at 16% CP at night while you sleep.
- If the patient has sensitivity issues, change all night gel to the lower concentration, week 1 syringe (10% CP).
If the patient has sensitivity issues, change all night gel to the lower concentration, week 1 syringe (10% CP).
Keep in mind that if there is not enough enamel for whitening, the patient may need additional treatments (such as composite bonding or ceramic veneers or crowns) to achieve the desired results.
4. BRUXISM (teeth grinding)
By far the biggest problem – 70% of the 2-week Enlighten failures is due to bruxism. Bruxists:
- They flex their trays causing leaks.
- They have a higher than average sensitivity, which leads to decreased compliance.
- They tend to have thinner enamel.
Signs of a bruxist: flat and worn edges of the teeth, visible dentin on the incisal edge, chipped teeth.
Recommended treatment plan:
Start with a standard 3-week course with the protocol below, but also, warn your patient that it may be necessary to extend by another 2 weeks if the results are not up to par or if they relapse earlier.
- Week 1 at 10% CP overnight, while sleeping
- Week 2 at 16% CP at night while you sleep
- Week 3 at 6% CP during the day, for one hour every day
- ( + if needed)
- Week 4 at 16% CP during the DAY for 3-4 hours
- Week 5 at 16% CP during the DAY for 3-4 hours
If the patient has sensitivity issues, change all night gel to the lower strength, Week 1 syringe (10% CP).
5. EXPECTATIONS
Some patients may have unrealistic aesthetic expectations. They may seek a false white appearance that can only be achieved with porcelain or composite restorations. Make sure your patients understand exactly what whitening can achieve and do not give them any assurances, except for the B1 guarantee, which can be measured using a shade guide.
Unrealistic expectations would be completely symmetrical teeth, with perfect edges, all teeth being a solid, opaque shade (often a very bright white). In a word, perfect teeth, which doesn't really happen naturally (if they do, they are extremely rare).
Realistic expectations are naturally occurring, aesthetically pleasing teeth that will likely have very similar, but not completely identical, correlated teeth on the opposite side, a uniform color with some natural translucency, potentially slightly worn edges from normal wear.
Recommended treatment plan: Standard 3 weeks of at-home whitening, but warn that they may need an additional 2 weeks. If, at the end of 5 weeks, your patient is still dissatisfied (due to unrealistic expectations related to whitening alone), explain that they may need additional treatment, such as composite bonding or veneers, as not much can be achieved with whitening alone.
6. TETRACYCLINE STAINING
This can be severe or mild. It is classified into 3 grades. Tetracycline patients who have any of the other 5 aspects above are more difficult to whiten.
Recommended treatment plan: Minimum 5 weeks of at-home whitening. If the case is severe, increase the minimum number of weeks to 8 and bring the patient back for re-evaluation.
What do I do if my patient whitens to a good standard but then relapses early?
Sometimes patients confuse the rehydration process with regression expressing concern or dissatisfaction, so be sure to explain this from the beginning to avoid misunderstandings. During the whitening process, the peroxide dehydrates the teeth in order to successfully penetrate them. A dehydrated tooth appears much brighter, sometimes a chalky white, but within a few days of stopping treatment, saliva and diet rehydrate it, stabilizing the color, this being the true result of whitening.
If you have determined that your patient did indeed have an early relapse, not the rehydration process, then this is a sign of insufficient whitening. This may occur if the patient was a difficult case that was not diagnosed at the beginning or due to patient compliance. In this case, reevaluate and prescribe the patient another 2 weeks, and in cases of severe relapse, start with 7 consecutive nights of whitening, then start an extended replenishment regimen to lock in these results and stabilize the shade, in the following sequence:
- 1 night per week x 4 applications
- 1 night every 2 weeks x 4 applications
- 1 night per month x 4 applications
- 1 night every 2 months x onwards
Remember to charge an appropriate fee for the additional weeks required for difficult cases and be sure to explain to patients exactly why they are classified as a difficult case. As much as Enlighten is an in-depth whitening process and a patient’s best chance of achieving an excellent teeth whitening result, it is by no means a miracle treatment and is not a one-size-fits-all treatment. It is a treatment that must be tailored to each individual’s needs and desires.
There you have it! Don't forget, you can use the mnemonic APE BET to keep them in your memory.
- Age
- Proximity
- Enamel
- Bruxism
- Expectations
- Tetracycline
Happy whitening!
Source: enlightensmiles.com
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