Fig.1
CASE 1
Initial situation. This patient already agreed to a bleaching procedure, which was thoroughly explained.
First appointment – total chair time 20-30 min
Once explanations and paperwork are done we only need 20 min with the patient for:
1. Initial picture with retractors and teeth in occlusion (it should take 1-2 minutes).

Fig.2
2. Initial picture with black background (1 more minute).

Fig.3
3. Identify the actual color with a shadeguide (3D Master Bleach Shadeguide) and take a picture (the most important picture is with the shadeguide) (3 minutes).

Fig.4
4. Polarized picture (without reflexes to better appreciate the color) (1-2 minutes to add the filter to the camera lens and take the picture). This is best done with a black background to prevent light distractions from color evaluation.
5. Impressions (digital or alginate) no need of occlusion registration (max 10-12 min).Second appointment – total chair time 30 minutes.
When the tray is ready. Could be whoever is trained (could be dentist, assistant, secretary, manager) to give the patient instructions. In Europe patient does the first application in the clinic, for European regulation, and must wait for supervision in the controlled setting of the reception/waiting room.

Fig.5
Third appointment – total chair time 15 min. After 1 week of bleaching at home. Appointment for a control. Picture after 7 days of bleaching, patient had no sensitivity. He used 16% carbamide peroxide, White Dental Beauty Teeth Whitening gels, per 2-4 hours a day with bleaching soft trays 1 mm. thickness.

Our suggestion to choose the right at home gel is to use a well-known brand, to assure you have a high quality gel that won´t create a damage to your enamel (high concentration and acidic whiteners are more likely to cause damage). The use of a neutral in-office bleaching agent gel produced the same whitening degree than an acid bleaching gel but with reduced risk and intensity of tooth sensitivity (Loguercio AD. et al) and lower risk to create structural defects of your enamel. Some of the best brands are Opalescence Go, Zoom from Philips and White Dental Beauty. All of them have an important background with different bleaching options, (5–18% carbamide peroxide, which equals 1.6–6.0% hydrogen peroxide) or 6% hydrogen peroxide. In general, it is recommended that the 5-10% carbamide peroxide be used 8 h per day, and the 15–18% carbamide peroxide 3–4 h per day. The 6% hydrogen peroxide 30min-1h per day.

As a brand we proposed White Dental Beauty as the first option as we are using it and we are very satisfied not only with the results, but as it is one of the best quality products in the market: we have really low rate of sensitivity thanks to the neutral pH of the product and we have a very good marketing strategy behind it.
The available options with White Dental Beauty Teeth Whitening gels, are:
– 6% hydrogen peroxide for 30-60 min a day for 1-2 weeks.
– The 16% carbamide peroxide for 2-4 hours a day for 1-2 weeks.

– The 10% Carbamide peroxide for 8 hours a day, usually used during the night for 1-2 weeks.

– Carbamide peroxide 5% overnight for 4-8 weeks used in patients with sensitive teeth. 
This patient chose 16% carbamide peroxide, because it better fit her lifestyle, as she wanted to wear the bleaching tray during the day and because she had the 2-4 hours a day time to bleach. She works at home with the computer.

Fig.6
Fourth appointment – total chair time 15 min
1 week after. For a control. In the picture on the left we can see before bleaching and on the right we can see the picture after bleaching.
Total: bleaching for 2 weeks with a soft tray.

Fig.7
CASE 2
In this clinical case the patient wanted to bleach in the clinic, he liked the idea of having bleached teeth in only 1 hour. Everyone at the beginning wants faster results. In general, when explained the pros and cons of the different options, patients use to change his/her mind and tend to use the tray to bleach at home.
Our patient is a busy person. He doesn’t like to wear trays during the night. He chose the 6% peroxide hydrogen for only 30-45 minutes a day to use after dinner before going to bed, whilst he answer e-mails.

Fig.8
A gray neutral card is used to better compare before and after bleaching pictures (color calibration).

Fig.9
In the picture, only the upper arch is bleached. We always bleach the first 7 days only the upper arch, in order to let the patient appreciate how bleaching is actually bleaching. They can appreciate much more satisfactory effects of the bleaching with this approach, than with a before and after picture.

Fig.10
He continued the bleaching for 1 more week both in the upper and lower arch at the same time.

Fig.11
Before (left) and after (right) bleaching pictures split to better appreciate the color differences.

Fig.12
CASE 3
This patient didn’t ask to bleach their teeth. She decided to improve her smile with composites, even if she should have undergone an orthodontic treatment before, which she denied. Before any restorative treatment, we always include the bleaching in the treatment plan. Patients usually accept the Bleach and Restore approach, which means to bleach before restoring in order to improve the smile.

Fig.13
Once information is given and consent is obtained, we proceed with the initial pictures and fabrication of the bleaching soft tray.
Here you can see the initial picture with retractor and patient biting.
In this first appointment, impressions and record pictures are taken, and a gel solution is chosen with the patient according to his/her lifestyle.
This patient chose to use the tray during the night, as she is usually not home, not even in the evening hours, as she is a restaurant owner. No sensitivity was reported (if sensitivity is reported, we can prescribe the 5% carbamide peroxide, White Dental Beauty Teeth Whitening gels), but the night-time option in non-sensitive subjects is 10% carbamide peroxide for 2 weeks, 8 hours a day. She used the White Dental Beauty Teeth Whitening gels.

Fig.14
Initial picture taken during the first bleaching appointment.

Fig.15
Initial picture taken during the first bleaching appointment.

Fig.16
Initial picture with the Vita shade guide.

Fig.17
Initial polarized picture with the Vita Shade Guide.

Fig.18
Initial polarized picture with the certified neutral gray as a reference to balance colors to better compare initial and final pictures.

Fig.19
We took digital impressions (Trios), and with the digital model (printed with the FormLabs Form 2 3D printer) in the same way that we prepare the tray on a cast model we can create our tray on the resin model. What changes is the preparation of the model before creating the tray, with the vacuum forming machine.

Fig.20
As you can see, the tray is very thin and soft. Hence it should be very precise to prevent the gel from spreading outside the tray.

Fig.21
Verifying the precision of the bleaching tray.

Fig.22
Results after 2 weeks at home whitening procedure, with the trays and 10% carbamide peroxide.

Fig.23
Final picture with black background

Fig.24
Initial and final color shade.

Fig.25
Before (left) and after (right) bleaching pictures split to better appreciate the color change.

Conclusions

How to pick out the best whitening system? Which is the concentration that I should choose?

The first tip is to choose a trustworthy brand with reputable, trusted manufacturers.

Remember that the only really bleaching products are the peroxides. 

In this article we have seen different clinical cases in which we used the same protocol – 2 weeks at home whitening with bleaching trays – but with different concentrations; 6% hydrogen peroxide in one case 30 min a day, 16% carbamide peroxide for 2-4 hours a day, and 10% carbamide peroxide during the night. Good results were provided in all the cases.

If you respect the suggested times of bleaching, depending on the concentration used, you will reach the same level of bleaching with any of the bleaching options available on the market.

The in office bleaching option is only performed when the patient wants, or needs, immediate results. The patient is always informed about the disadvantages of the in office bleaching procedure (augmented sensitivity and less lasting results).

Amongst the at home bleaching options, carbamide peroxide takes longer to break down and releases approximately 50% of the bleaching power in the first 2 hours, and can be active for 6 hours. Hydrogen peroxide is much faster, takes much less time to be effective, less than 1 hour. In the clinical reality we choose the gel depending on the patient lifestyle as all gels are performing good and causing very few sensitivity issues, the main bone of contention until recently when talking about bleaching. I will give you a few examples.

– For patients who don’t like sleeping with the tray and don’t have a lot of free time during the day, use 6% hydrogen peroxide because it is the faster one.

– For patients working at home, hence having time to use the tray during the day, we suggest the 16% carbamide peroxide.

– For patients who have no problem using a soft thin tray during the night, we suggest the carbamide peroxide 10% during all night.

– Carbamide peroxide 5% is the perfect option to use during the night for a prolonged period, up to 1 month and more, for patients who usually can’t use bleaching products because of sensitive teeth. 

It seems logical to use a trusted brand with good support and research behind, when choosing a bleaching system for your patient. When making the decision of which concentration to use, it seems appropriate to choose one depending on the patient’s lifestyle.

In this article, the first clinical case is provided by Dr. Marie Clement, Silver Styleitaiano Member from France, who always kindly shares protocols, cases and knowledge. Thanks for sharing.

Bibliography

Loguercio AD, Servat F, Stanislawczuk R, Mena-Serrano A, Rezende M, Prieto MV, Cereño V, Rojas MF, Ortega K, Fernandez E, Reis A. Effect of acidity of in-office bleaching gels on tooth sensitivity and whitenings: a two-center double-blind randomized clinical trial. Clin Oral Investig. 2017 Dec;21(9):2811-2818.