Indications of In-Office Topical Fluoride Treatments: Varnish, Foam

techniques article
WHITER, BRIGHTER, HEALTHIER SMILES
ASSISTANT
FOR THE CHAIRSIDE of
Indications
In-Office
FREE 1
Topical
Fluoride
CEU COURSE
CREDIT!
Treatments: Varnish, Foam, and Gels
By Shannon Pace Brinker, CDA CDD • CPS Magazine www.cpsmagazine.com
W
ith so many bleaching materials on the market today, it is really hard to determine which product to use and why. As dental assistants, we are not
trained to decide what is the best percentage of bleach; what is safest for a particular patient; and, most importantly, whether to use an in-office or
at-home treatment (or both). Most of the time we draw upon our own experience and our patients’ responses. In this article, we used several
different
from Pace
Heraeus
and SDI. We
chose, patients
varying ages
and used differing methods for predictable results.
by systems
Shannon
Brinker,
CDA
CDD,ofEditor
in Chief,
Contemporary Product Solutions • www.cpsmagazine.com
HOW DOES WHITENING WORK?
The peroxide in the whitening solution breaks down into water and oxygen ions. The oxygen ions enter the enamel and dentin and are attracted to the staining
molecules. The oxygen ions attack and destroy the double bonds, leaving shorter stain molecules. Double bonds create discoloration and, once broken, the
discoloration and the compounds are removed.
WHAT ARE THE DIFFERENCES BETWEEN HYDROGEN AND CARBAMIDE PEROXIDE WHITENING?
Hydrogen is used for most in-office procedures and can cause more sensitivity. Hydrogen is usually activated by light and is stronger and faster than carbamide
peroxide. It is easier for the patient because the dental team does all the work. Carbamide peroxide is recommended for whitening tray wear and can be used day
or night. Carbamide causes less sensitivity and has more effect on dark stains but must be worn longer for more effective results.
COMPREHENSIVE ORAL EXAM AND RECORDS
The dentist must first make an assessment as to whether the patient is an ideal candidate for bleaching. We suggest that the patient first undergo a thorough
dental hygiene visit to remove extrinsic stain, calculus, and plaque. During this initial visit, we can provide dental X-rays, periodontal charting, digital
photography, and pre-operative study models for home-trays if needed. Make sure to take pre-operative photos with and without a shade guide to prove
Shannon
Pace Brinker,
shade
change.
CDA a National and
International Speaker
and published
author.
WHO
IS A CANDIDATE?
Shannon,
Editor
in Chief,
Teeth
that are
yellowish-brown
(a shade range) and typically stained from aging tend to whiten more rapidly than teeth that range from gray to grayish-brown
her husband
Erik,Mktg
own to check this. Patients who consume large quantities of dark soft drinks, tea, coffee, grape juice, red wine, and/or use tobacco will
(Cand
to D)????
Mike…ask
Contemporary
Product
achieve greater success with the in-office procedure as compared with an at-home bleaching procedure. White stains do not go away and may even get lighter
Solutions,
which provides
during
the whitening
process. Teeth with tetracycline stains, decalcifications, traumatic injuries, or root canal therapy may require additional visits and possible
product
the
home
tray reviews
alliancefor
to achieve
optimal results. Please note that bleaching is not recommended for women who are pregnant or breast-feeding.
complete dental team. It is
the only dental editorial that
combines
product
WHAT
ARE
THE review
MAINforCAUSES OF SENSITIVITY?
the of
whole
team.sensitivity is caused from recession, abrasion, erosion, and dehydration. During the first 24 hours of treatment after in-office whitening some
Most
the time,
patients
mayPace
experience
Shannon
Brinker, some tooth sensitivity or pain. Normally that goes away after 24 hours, but in rare cases can persist for longer periods of time. Most
offices
CDAwill
is arecommend
past faculty sodium fluoride (Remin Pro Voco) (MI Paste GC America) be placed in the tray for 30 minutes before or after the whitening process.
member at the Dawson
the history, efficacy, and indications for three
Academy and Spear
Introduction
PRODUCT
TYPES
Education. She
is an
types of topical fluoride treatments.
There
aremember
three basic
types of whiteningAprocedures
our office offers;
they
are: demonstrated
active
of the
study conducted
in the
1990s,
AACD. Shannon
is whitening)
the
• In-Office
(one-hour
with take-home
a steadytraysrate of decline of instances of
first auxiliary
to sit on
thewhitening) Day or Evening wear
• Take-Home
(custom
tray
coronal caries through the 1980s. This Varnishes (Sealants)
AACD Board of Directors.
• Pre-Filled
(disposable
trays)decline was attributed to an increase in oral
Shannon was
selected whitening
one
Sodium Fluoride (NaF) varnish was first
of Dentistry Today’s Top
health education regarding diet and oral
introduced in the United States in 1964.7 The
100 Clinicians of 2009,
1
hygiene, TRAYS
and an increased awareness about
PRE-FILLED,
WHITENING
2010, 2011 andDISPOSABLE
2013.
first generation available was a yellow-colored
The
Venus
Ultra by
tray that
pre-filled with
an 11.2% mint-flavored hydrogen peroxide gel that is worn for one hour a day for up
the benefits
ofis applying
fluoride-containing
She
was White
also selected
as Heraeus is a disposable
resin
considered
the tray
standard
of care
25
to Dental
seven days.
EachReport
set comes
and lower
tray that self-adheres
the toothsealants
arches with just
a pinch.
This pre-filled
is for teenagers
andfor
young
Products
25 with an upper
topical
treatments
such as todental
years. The next generation available was a
adults
are looking
forina lighter, brighter smile.
mostwho
influential
women
(i.e., varnishes), foams, or gels to the teeth of
whiter, tooth-colored resin, which was slightly
dentistry and Dr. Bicuspid’s
individuals of all ages in moderate-to-highDental Assistant Educator
more costly, but preferred by some patients. The
risk groups for caries.2-6 This article reviews
of the year for 2012. She
third and most recent development was a clear/
is the Editor in Chief for
transparent variation, making varnishes viable
Contemporary Product
Solutions and consultant for
1
for use with bleaching procedures.
many dental manufacturers.
For information on dental
The primary indications of varnishes are as part of
assistant programs, please
a caries prevention program that includes other
contact her at 757-285-9477
topical fluorides, such as toothpastes. However,
or email at
in 1994 the Food and Drug Administration
shannon@cpsmagazine.com.
Venus White Ultra 11.2%.
Figure 1–Dry teeth with a cloth or paper
towel before placement of the Venus
White Ultra. Remove from packaging
and place strip on upper teeth.
2012 SELECT
18
Fax Your Order:
Figure 2–Mold
the Venus White
Ultra
granted
approval
pre-filled strip to the arch form
desensitizing
agent
of the upper arch.
3–Moldvarnish
the Venus White
of Figure
fluoride
as Ultra
a
strip to 7the arch form
andpre-filled
cavity
liner.
of the lower arch.
Varnishes are clinically proven to provide at least
25% caries prevention in moderate-to high risk
children, adolescents, and adults when applied
between 2 and 4 times annually. Varnishes are
1.800.732.7023 24 Hours
3
Figure 1. Peel Back the blister pack of Profluorid
Varnish (VOCO) in Carmel flavor.
Figure 2. Take Brush and place in varnish.
Figure 4–Retracted view of the Venus
White Ultra in place on the maxillary
and mandibular arches.
Figure 5–Patient is instructed to wear for
1 hour per day for 7 days. Patient is then
instructed to return for a follow-up visit
and shade check with photos.
Figure 3. P lace Profluorid varnish on all teeth and
instruct patient to close and move saliva
Figures 6 and 7–Before and after, using the Venus White Ultra for 7 days.
around teeth to moisten varnish. Instruct
patient to avoid alcohol, brushing and
flossing for 4 hours.
FABRICATION FOR WHITENING TRAYS
There are several materials to choose from when it comes to the impressions for the whitening trays. In my practice we use both polyvinyl and alginate. What is very
important is the detail that is captured in that impression. The whitening tray must seat and fit properly. Over the years, I have been asked to I block out my model
the only
topically
fluoride
the calcium
and calcium
deposits.
The
whenalso
fabricating
a whitening
tray. Isapplied
it necessary
to cut the ion,
papillatogether
to minimizewith
tissue irritation?
From myions
own experience
in performing
over
400sodium
whiteningfluoride
8
procedures
within the
last 2 years, it has
no difference
whether the block
or papilla
has been
removed
the tray.
The choice is really
the patient.
treatments
recommended
formade
all ages.
accumulated
inoutthe
tubules,
causes
a from
works
immediately
whileup to
the
calcium
We offer several types of whitening in our practice. When discussing
compliance
with the patient,
it is very
important
to help the
patient
to understand
that this is
precipitation
of
calcium
fluoride,
which
deposits
store
and
release
fluoride
over
The typeand
of varnish
depends
an investment
we do notchosen
want to waste
theirlargely
time if they are not going to follow-up. In our practice we have nighttime wear and daytime wear. We allow the
effectively
seals
the
tubules.
According
time
which
makes
it
the
perfect
formula
patient
to
choose,
which
makes
them
accountable.
Poladay
by
SDI
home-tray
whitening
gives
the
patient
the
option
of
a
30-minute
whitening
at
9.5%.
We
also
offer
on the patient’s age, setting in which they
the patient a polanight that is an overnight wear carbamideto
peroxide
gel survey,
at 10%. Teeth-whitening
gel will
only whiten
teeth. and long term results.
a user
over 85 % of
patients
for natural
immediate
techniques article
2
receive the varnish (i.e., public program
or private dental practice), patient were completely free of pain after only The perfect formula for immediate and
preference, and whether a whitening one treatment with Profluorid Varnish. long term results. Profluorid L is free
As well as rapidly sealing the dentinal from colophony, glutaraldehyde, gluten
procedure is performed.
tubules,
Profluorid Varnish
colophony, or methacrylates. Profluorid
Another
photo
Profluorid Varnish (VOCO, Briarcliff
L can be used after cleaning procedures,
for
this?
also
causes
calcium
fluoride
deposits
to
Manor, NY ) is an easy to apply version
cervical hypersensitivity, periodontal
of the second-generation varnishes form on the tooth surface. These deposits treatment, after occlusal adjustments,
available in single doses. Also containing protect the tooth from acid attacks,
sensitive margins, before provisional are
5% sodium fluoride, this tooth-colored promote remineralization and contribute to seated, sensitivity from bleaching.
Figure 1–Make sure trays are clean and
Figure 2–Remove
syringe from case and load
Position tray over your teeth and gently press
varnish is naturally sweetened
with the long-term formation
of fluoroapatite.
dry prior to applying SDI Poladay 9.5%
the tray with SDI Poladay 9.5%, depress the
tray to move the gel into place. Do not press too
Xylitol. While the primary indication Xylitol, which hasplunger,
a proven
cariostatic
and fill each tooth in the tray with a
hard—only enough to seat on teeth. Wear tray
Foams
is treatment of sensitivity, it is equally effect in addition pearl
to its
taste-enhancing
of gel.
One syringe will be used
for two
for 30 minutes a day from 10 to 14 days. Remove
days ofto
whitening
or two applications of top
trays after 30 minutes. Brush teeth and inside of
effective
in
caries
prevention.
Profluorid
properties,
is
also
added
the
varnish
In
1993,
Sodium Fluoride (NaF) foams
Whiter Brighter You
and bottom.
whitening trays to remove access material.
Varnish adheres well to wet surfaces
were introduced to the United States
unlike most varnishes where teeth must
market. These fluoride foams only
be dry before application. It is a tooth Clear 5% Sodium Fluoride
underwent a short evolution and include
shaded and available in four great tasting Liquid Varnish’s
acidulated phosphate foam (APF) for
flavors: melon, cherry, mint and my
deep infiltration, and neutral fluoride foam
favorite carmel. Comes in a blister pack Profluorid L Varnish (VOCO, Briarcliff for restorations or individuals sensitive to
Manor, NY) is a clear liquid thirdcontaining a brush and the varnish.
generation varnish specially formulated to acidic fluorides. Neutral foams provide
not interfere with bleaching procedures. fluoride without damage to the surface of
restorations and are a good alternative for
Components and effect of This varnish is indicated for a host of other acid-sensitive patients.
Figures 3 and
and after
full face. sealing
applications
as4–Before
well and
including
VOCO Profluorid Varnish
the surfaces of damaged teeth and has Indications for fluoride foams are
Profluorid Varnish is a colophony-based effective double protection of 5% sodium similar to other topical fluorides (i.e.,
varnish containing 5 % sodium fluoride fluoride and calcium deposits. Effective desensitization and cavity prevention),
(22,600 ppm fluoride). The fluoride double protection of 5% sodium fluoride but they are most effective in primary
Figure 4. P lace a few drops into the
mixing well and stir with
brush
4
5
Figure 5. P lace on areas that are
sensitive from whitening
Figures 5 and 6–Pre Op Shade A1 to a BL4.
To Order, Call Us Toll-Free:
1.800.372.4346 8am–9pm, et
19
techniques article
teeth andWHITENING
on the proximal surfaces. Recommended mainly
IN-OFFICE
9
Dental team members can help their patients decide if topical
application
would
be beneficial,
acknowledging
for children,
one study
states way
thattoall
agesteeth.
canVenus
benefit
from
a anfluoride
In-office
bleaching provides
the quickest
whiten
White
Max is
in-office whitening
treatment
that consist
of a 38% hydrogen
peroxide gelthat
that is
applied
for 2 (30)
minute sessions
without the
use of
a light. The
is instructed
after the in-office
whiteningfor
to follow
upmost
the treatment
with 2 weeks
of take-home
with low-risk
caries
likely would
not benefit.
4-minute
application
of fluoride
foam
instead
of apatient
gel, since
the patients
whitening (One hour a day for 14 days
or the patient may choose to have another in-office whitening procedure.).
10,11
foams are equally effective.
These foams have been marketed
as “minute-foams,” but just as with gels, a minimum 4-minute
contact is recommended for adequate fluoride infiltration.
Examples of neutral foams available are Topex Neutral Fluoride References
Foam (Sultan Healthcare, Inc. Hackensack, NJ) and Kolorz 1. Rozier RG, Beck JD. Epidemiology of oral diseases. Curr Opin
Neutral Fluoride Foam (DMG America, Englewood, NJ).
Dent.1991;1(3):308-15.
Acidulated phosphate fluoride foam is available in products like 2. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride gels for
Denti-Foam Topical Fluoride Foam (Medicom USA, Augusta,
preventing dental caries in children and adolescents. Cochrane
CA). These foams claim deeper fluoride infiltration and lengthier
Database Syst Rev. 2002(2):CD002280.
fluoride retention in saliva after treatment.
3. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride gels for
Foams provide an average 25% caries reduction rate in
preventing dental caries in children and adolescents. Cochrane
Figure 2–Pre Op Shade Tab D3
adolescents and adults with moderate-to-high-risk for caries.12
Database Syst Rev.2002(3):CD002279.
Patient’s teeth have been pumiced. Retractor and
Since foams are most effective on primary teeth, these rates can
gingival barrier have been placed.
be much higher—up to 41%—in the children in moderate-to- 4.Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride
(toothpastes,
mouthrinses,
gels, or varnishes) for preventing
13
high-risk populations.
Venus White Max
Gels
caries in children and adolescents. Cochrane Database Syst
Figure 1–Full Face Pre-Operative
Rev.2003(4):CD002782.
Photo with Shade tab.
5. Rozier RG. Effectiveness of methods used by dental professionals for
the primary prevention of dental caries.J Dent Educ.2001;65(10):1063Fluoride gels became available for use in the United States as
72.
early as the 1960s. Like foams, they are available in neutral
and acidulated phosphate fluoride (APF) compounds. Gels are 6. Van Rijkom HM, Truin GJ, van’t Hof MA. A meta-analysis of
usually only recommended for use in older children, adolescents,
of clinical studies on the caries-inhibiting effect of fluoride gel
and adults to reduce the risk of swallowing, but gels can be
treatment. Caries Res.1998;32(2):83-92.
applied with a toothbrush instead of the standard tray method 7. D
ental Products Report. Hygiene Article. Making the case for
to further reduce this risk.14
fluoride varnishes. http://www.dentalproductsreport.com/hygiene/
article/making-case-fluoride-varnishes. Accessed April 5, 2013.
The indication for fluoride gel is limited to caries prevention
or reduction. Many dental professionals prefer the highly acidic 8. Q
uock RL, Warren-Morris DP. Fluoride varnish: the top choice for
APF gels due to their supposed higher fluoride uptake and
professionally applied fluoride. J Mich Dent Assoc.2011;93(5):42-8.
higher saliva retention after treatment. However, studies confirm
9. J iang H, Bian Z, Tai BJ, et al. The effect of bi-annual application of
that neutral
fluoride
gels
areProequally
effective and
not30have
Figure 3–Mix
the Venus
White
38% hydrogen
Figuredo
4– After
minutes, suction off whitening
5–Suction off Venus White Max and rinse.
APF foam on dentalFigure
caries
increment in primary teeth: 24-month
5
the ability
to etch
restorative
materials
do.
peroxide
gel. Apply
1 mm of Venus
White Maxlike
gel APFs
agent
and reapply for another 30-minute session.
Remove the gingival barrier and retractor. Take a
clinical trial. J Dent Res.2005;84(3):265-8.
final photo and instruct patient on the use of the
to facials of teeth for 30 minutes.
Examples of available fluoride gels include Zap Fluoride Gel
trays.
10 .Wei SH, Hattab take-home
FN. Fluoride
retention following topical
(Sultan Healthcare, Inc. Hackensack, NJ), Phos-Flur Fluoride
application of a new AFP foam. Pediatric Dent.1989;11(2):121-4.
Gel (Colgate/Polmolive, New York, NY), and Sensodyne
ProSchmelz Fluorid Gelee (GlaxoSmithKline Consumer 11. Wei SH, Hattab FN. Enamel fluoride uptake from a new APF
foam. Pediatric Dent.1988;10(2):111-4.
Healthcare, Brentford, Middlesex, United Kingdom).
merican Dental Association Council on Scientific Affairs.
Fluoride gels provide an average 25% caries reduction rate in 12. A
Professionally
applied topical fluoride: evidence-based clinical
moderate-to-high caries risk groups, similar
to
foams
and
RESOURCES:
15
recommendations.
J Am Dent Assoc.2006;137(8):1151-9.
varnishes.
References
Conclusion
13. E
vans
D. APFand
foam
does reduce
caries inVital
primary
teeth.
Evid Based
1. Haywood VB. Tooth Whitening:
Indications
outcomes
of Nightguard
Bleaching.
Hanover
Park,
Il: Quintessence Publishing Company
Inc; 2007.
Dent.2007;8(1):7.
2. Matis BA. Tray whitening: what the evidence shows. Compend Contin Educ Dent. 2003; 24(4A):354–362.
14. Ribiero CC, Lula EC, Azevedo IM, et al. Salivary retention after
3. Gottardi MS, Brackett MG, Haywood VB. Number of in-office light-activated bleaching treatments
All three topical fluoride treatments—varnishes,
foams, and
application
of fluoride
gel using toothbrush
or tray: a crossover trial.
needed to achieve patient satisfaction.
Quintessence
Int. 2006;37(2):
115–120.
gels—reviewed in this article provide at 4.least
25% caries
Brazappraisal:
Oral Res.2012;26(6):493-7.
Browning WD, Swift EJ. Critical
comparison of the effectiveness and safety of carbamide
prevention in moderate-to-high-risk groupsperoxide
of all whitening
ages. This
agents at different concentrations.
15. W hitford GM, Adair SM, Hanes CM, et al. Enamel uptake and
Restor
2007;19(5):289–296.
means that it is not a question of if patientsJ Esthet
at risk
forDent.
caries
patient exposure to fluoride: comparison of APF gel and foam.
Cooper
JS, Bokmeyer
should use topical fluorides, but how often5.and
which
type. TJ, Bowles WH. Penetration of the pulp chamber by carbamide peroxide bleaching
Pediatr
Dent.1995;17(8):199-203.
agents. J Endod. 1992; 18:315–317.6.
McCaslin
AJ, Haywood VB, Potter BJ, et al. Assessing dentin color
changes from nightguard vital bleaching. J Am Dent Assoc. 1999;130:1485–1490.
7. Hall DA. Should etching be performed as a parta
Figure 7
Final Fill Face Photo
of a vital bleaching technique? Quintessence Int. 1991;22:679–686.
CE CREDIT
8. Haywood VB. Treating sensitivity during tooth whitening. Compend Contin Educ Dent. 2006;26(9):11–20.
9. Leonard RH, Haywood VB, Phillips C. Risk factors for developing tooth sensitivity and gingival irritation
associated with nightguard vital bleaching. Quintessence Int. 1997;28: 527–534.
All participants scoring at least 80% on the examination will receive a certificate
10. McKamie
A. Deep
one practice’s
protocol
for enhanced a
patient
satisfaction.
verifying 1 CEU Credit. To take
the test
andbleaching:
receive
credit,
or request
sample
please go
Contemporary Esthetics. 2007;10:12–19.
to http://cpsmagazine.com/one-ce-credit-topical-fluoride-treatments
20
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