Bleaching Materials - REALITY Publishing Company
Transcription
Bleaching Materials - REALITY Publishing Company
Bleaching Materials REALITY’S CHOICES Power 1. Zoom! Discus 2a. Opalescence Xtra Boost Ultradent 2b. Opalescence Xtra Ultradent 3. Niveous Shofu Assisted 1a. Opalescence Quick Ultradent 1b. White Speed Discus 2. Polazing SDI Home 1. Opalescence/Opalescence PF Ultradent 2a. Day White Excel 3 Discus 2b. Nite White Excel 3 Turbo Discus 2c. Zoom Take Home Discus 3. Nupro White Gold Dentsply Professional 4a. Poladay SDI 4b. treswhite Ultradent ©2005 REALITY Publishing Co. Vol. 19 The Ratings 53 Bleaching Materials Power Price Product Per Session Activation Unit/Mode $1,495.00 $85.00 Ultraviolet System Zoom! Discus Opalescence Xtra Boost pH Flow1 Separate, $150 25 8.9 5.0 Automix Syringe 60 min 105 min Radiometer N/A $67.90 Chemical N/A 38 7.6 5.0 Gel/gel: syringemixed 60–90 min 90–120 min N/A $63.00 Light Optional N/A 35 4.3 5.0 Premixed 45 min 75 min $96.97 Chemical, Light Optional Ultradent Niveous N/A Shofu Approx. Appt. Length % H2O2 Ultradent Opalescence Xtra Manufacturerrecommended Total Bleach Type of Mix Time/Appt N/A 27 5.0 3.9 Gel/impreg- 30 min with light nated microbrush 45 min without light 60–75 min Assisted Cost/ml % of Carbamide Peroxide pH Flow1 Opalescence Quick $5.00 35 6.1 5.0 None Provided or Recommended $6.94 35 equivalent 5.6 4.5 None Provided or Recommended $4.81 35 5.5 5.0 None Provided or Recommended Ultradent White Speed Discus Polazing SDI 1 0 MOST FLOW 54 Soft Tissue Protection Product The Ratings 1 2 3 4 5 LEAST FLOW ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Power Average Shade Changes Product Zoom! Discus Opalescence Xtra Boost Sensitivity (% of patients) During Post Appt. Appt. Desensitizer included? Home Bleach included/ suggested? Initial Clinical Evaluation 1 month 3 months 0 30 Yes Yes 5.5 5.1 0 100 No Yes 3.0 2.7 0 N/A No Yes N/A N/A 0 N/A No No N/A N/A Ultradent Opalescence Xtra Ultradent Niveous Shofu Home Cost/ml Product Opalescence/ Opalescence PF Kit Refills Dentsply Professional Poladay SDI treswhite Ultradent Flavors 5.0 6.3– 6.6 3: Regular, Mint, Melon 0.5mm Reservoir Material Marketing Materials Marketing Manual (Blueprints for success), Postcards, Counter Displays, Posters, Statement Stuffers $2.50 $2.15 Hydrogen 7.5%, 9.5% 5.0 8.6– 9.5 1: Cool Mint 0.4mm Not Nothing specific, just on Recommended bleaching in general $5.65 $6.09 Hydrogen 6% 5.0 6.0 1: Mint 0.4mm Not Recommended Nothing specific, just on bleaching in general $5.36 $5.87 Hydrogen 4%, 6% 5.0 6.5– 6.6 1: Mint 0.4mm Not Recommended Nothing specific, just on bleaching in general $2.92 $1.96 Carbamide 10%, 15% 5.0 5.7– 6.1 1: Mint 0.4mm Triad Gel VLC Block Out Resin Brochures, Postcards, Statement Stuffers $2.24 $1.52 Hydrogen 3%, 7.5%, 9.5% 5.0 6.0– 6.4 1: Spearmint 0.4mm Spacer resin Postcards, Brochures, Patient assessment worksheet $4.00/ patient N/A Hydrogen 9% 5.0 6.6 2: Mint, Melon N/A N/A Large cards and posters Discus Nupro White Gold pH $2.17 Discus Zoom! Take-Home Flow1 $2.50 Discus Nite White Excel 3 Turbo Thickness of Tray Material After Fabrication Carbamide 10%, 15%, 20% Ultradent Day White Excel 3 Type of Peroxide and Concentrations ©2005 REALITY Publishing Co. Vol. 19 LC Block-Out The Ratings 55 Bleaching Materials Bleaching is dentistry’s only purely cosmetic procedure. In other words, there is no functional component to bleaching. Lighter or whiter teeth are not any healthier than dark teeth, nor do they allow more effective chewing or more distinctive speech. Nevertheless, it is the rare individual who does not desire whiter teeth. There are essentially two main types of bleach: power and home. A third type, assisted, has been used as a booster for home bleach. However, since several home bleaches are virtually the same concentration as those targeted for assisted procedures, the line between these subcategories is fuzzy at best. Power Bleaches With glitzy practice modes such as the dental spa movement, power bleaching continues to be heavily promoted. Nevertheless, the list of products in this subcategory is still relatively short. Criteria for Choosing a Power Bleach There are certain aspects of bleaching that all these systems share, but dissimilarities do exist. And many of the details of these protocols seem to be based more on empirical voodoo than solid clinical evidence. Do you need to use a light? This is, by far, the most controversial of all issues facing power bleaching. In our most recent clinical evaluation of each system, we placed black opaque tape over the left side of the bleaching light so we could effectively bleach one side of the arch with the light and one side without the light. Regardless of the manufacturer’s instructions, all patients in our evaluation were bleached for one hour. The results showed bleaching effectiveness was not influenced by the bleaching light. Before After Zoom! Discus Opalescence Xtra Boost Ultradent Opalescence Xtra Ultradent Niveous Shofu 56 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Lights do not seem to boost bleaching effectiveness. Nevertheless, since lights have no apparent untoward effects, they still may be utilized IF you don’t make unsubstantiated claims to the patient. How important is application time? Of the five products in this subcategory, the total, per appointment application times (as opposed to total appointment times) range from 30-90 minutes. We suggest longer is better, although patients tend to become uncomfortable after 60 minutes. It is also uncertain whether reapplying the bleach every 15 minutes or so is better than one application for the entire bleaching session, although intuitively, the former seems to be more effective than the latter. Does concentration of peroxide matter? The products we tested ranged from 25%-38%. But, if “more is better”, why would some manufacturers choose a concentration lower than others? There are two possible reasons: sensitivity and enamel damage. As the percentage of peroxide increases, the probability of sensitivity goes up proportionally. It follows, then, that lower concentrations should result in less sensitivity. The same applies to enamel damage, the incidence of which has been reported periodically in the scientific literature. Even though the evidence for this damage is anything but definitive, using a potentially less destructive product (lower concentration) could help to silence the naysayers. Does the pH matter? Along with concentration of peroxide, pH has been implicated in causing sensitivity. It follows, therefore, that a more neutral pH bleach would be less likely to cause sensitivity. How thick does the layer of bleach need to be? A general guideline would be a fairly thick layer, about 1.5-2.0mm. However, we believe the most important factor is to cover the facial surfaces of the teeth completely and keep the gel from drying out. Is sensitivity inevitable? Most patients will accept minor discomfort (no pain, no gain), but few will endure any level beyond slight sensitivity. Even though sensitivity did occur in our evaluation at various levels in the first 24 hours, it was virtually nonexistent after 24 hours, except for one patient. This means it will be short-term and should not be a factor for any patients. Nevertheless, several systems have companion products for desensitization to be on the safe side. The patient with sensitivity used MI Paste (GC) in bleaching trays overnight. The sensitivity was completely resolved when the patient awakened the next morning. ©2005 REALITY Publishing Co. Vol. 19 Should you encourage home bleaching to enhance the efficacy? If a patient was willing to wear a tray, why even bother with the power technique? With the leading candidates for power bleaching being those patients who don’t want to be bothered using a tray, it would seem that combining these two approaches would be an exercise in futility. That is, unless you realize superior results when both methods are utilized. It’s no surprise, then, that home bleach and tray material are either standard or optional in most power bleach kits. Does it require mixing? Of our CHOICES, three are automix, one is hand-mixed, and one is premixed. Obviously, no mixing is easier, less messy, less labor-intensive, and preferred, but auto-mixing is the next best alternative. Does it need to be stored in the refrigerator? All of our CHOICES recommend cold storage. However, just like most materials, you should bring the bleach back to room temperature prior to using it. The safest routine would be to take enough bleach out of the refrigerator to whiten all the patients that are scheduled the next day. If the next practice day occurs after a weekend or holiday, then the first staffer to arrive at the office in the morning should take the bleach out of the refrigerator. In this instance, it may be prudent to place the syringe of bleach in warm water if the first patient of the day is scheduled for bleaching. Cold bleach will probably not be as effective as room temperature or warm bleach. And, with at least one product, cold bleach was very runny—it needed to be warmed so it would not flow completely off the teeth. What is the cost/patient/appointment? This is the cost of the materials you would typically use during a power bleaching session assuming you bleach both arches for one hour, changing the bleach every 15 minutes (four applications). How do you protect the soft tissue? Due to their caustic nature, power bleaching materials have the potential to cause significant soft tissue injuries (that tend to heal uneventfully in 1-2 weeks). Even though power bleaching can be performed using several different types of gingival protection, the safest and most reliable is still a properly placed and sealed rubber dam. A well-sealed rubber dam allows the placement of the bleaching gel on the lingual as well as the facial of the teeth to be bleached. While we have no definitive proof that this total coverage hastens the bleaching effect, our clinical impression suggests this protocol is most effective. In addition, you can retract the gingiva around each tooth by ligating with waxed floss. This retraction allows you to bleach the entire tooth. However, most patients (and staff members) view the rubber dam as cumbersome to apply and uncomfortable. Therefore, a resin shield is the more popular method to protect the tissue and material for this shield is usually included in power bleach kits. Most, if not all of these materials are dispensed directly on the tissue from its syringe. If the material is runny, you need to cure for a few seconds as you place it around each tooth. If you try to apply to more than one tooth before curing, it will flow over the tooth, requiring you to chip off the excess using a #15 scalpel. This The Ratings 57 Bleaching Materials is time-consuming and a nuisance, since some of these materials set very hard. Unlike a rubber dam that is ligated around each tooth, there is no gingival retraction with a resin shield. As a matter of fact, you need to cover at least a narrow band of cervical tooth structure to ensure the gingiva is well protected. This area that is covered with the resin shield will not be bleached. Once you finish the arch, cure for an additional 20 seconds, although the heat produced by curing some of these products can cause discomfort. When you are finished bleaching, merely dislodge one end with an explorer or other instrument and the entire resin shield usually will peel off the gingiva in one piece. What protection is necessary for dental team members? Gloves, masks, and safety glasses will usually suffice when handling these caustic materials. It is very important that the peroxide be fresh when used. Otherwise, its ability to bleach teeth is reduced. All peroxides tend to oxidize when the bottle or syringe is opened or uncapped. The important message is to keep all bottles and syringes of peroxide tightly capped and refrigerated. Most products, however, should be brought back to room temperature before using. For our CHOICES in this category, we have broken down the costs to a common denominator: how much a two-arch bleaching session costs, assuming you are reapplying new bleach four times during the appointment (for a total of one hour of bleaching). Clinical Evaluation Initial evaluation 20 patients were randomly divided into four groups of five patients for each product. The products were used exactly as directed by the manufacturers. While this protocol precluded comparing the products using the same parameters (e.g., bleaching times were not all the same), it did allow us to gauge their relative effectiveness if you follow the manufacturer’s directions, which is, of course, what most of us are inclined to do, at least initially when we receive this type of product. Only one arch was bleached for each patient, allowing their opposing arch to act as the control. The average shade change produced by all the systems has been noted, but there is a built-in error in this calculation, since this number is highly dependent on the patient’s initial shade. Even though we randomized the use of the four systems, the beginning shades of the patients were not equal across the board. For example, if a patient starts out at A1, only one shade change (to B1) is possible. However, if a patient starts out at A3 and goes to B1, that’s eight shade changes. So the systems with the patients with darker teeth at baseline are more likely to have a higher score, regardless of whether they are more effective or not. All of these systems were, indeed, able to lighten most patients’ teeth to a reasonable degree, with the exception of two specific patients with tetracycline staining, where the results were mediocre at best. Any of them would be a viable alternative to BriteSmile, should you be so inclined not to sign any contracts. But, since the protocols were so varied, it is impossible at this time to say which is the best system based on these results. Follow-up evaluation Due to time constraints, only 10 patients were treated. Because of this limited number of patients, we could not come to any definitive conclusions, but the trends were fairly obvious. These observations are noted in the commentaries of each product. 58 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Zoom! (4.5) Cost: $1,495.00 Lip & Tongue Retractors: $9.50 Includes: • 1 Zoom! Chairside Lamp • 3 safety glasses • Assorted Marketing Materials • 1 video • In-office training Includes: • 1 bag of retractors (2 large & 4 medium) Procedure Kit: $85.00 Warranty: 1 year for lamphead, the power supply, the floor stand, and the power cord. The bulb has a 90-day warranty, but should last for 500 hours. Includes: • 3 retractor bibs • 2 light guides • 1 applicator brush • 1 dual barrel syringe of Zoom! Chairside Whitening Gel (4.6g/4.0ml) • 1 packet of vitamin E Soothing Oil (0.43g), with brush • 1 Packet of Protective Lip Cream (0.61g), with swab • 1 dual barrel syringe of Zoom! Take-Home (4% or 6%) or Day White (7.5%) Gel (2.4g) • 1 tray case • 1 pkg of gauze • 2 sheets of tray material • 1 syringe of Fluoridex 1.1% Neutral Sodium Fluoride Gel (1.3g) • 2 syringes of Liquidam (1.3g ea) • 1 cardboard holder for before & after photos REALITY’S CHOICES 1 Radiometer: $150.00 Lamphead: $480.00 What if it needs repairs? Contact Discus at 888-427-9279. Is there a loaner program? Yes. Will send a replacement immediately. No charge for units under warranty. Shipping charge may apply to units no longer under warranty. Shelf Life: 1 year refrigerated Best marketing program by far Coolest looking unit Most time-consuming Each patient kit is most expensive MSDS: Not included Cost/patient/appt = $85.00 (1 Procedure Kit) Composition of Bleach 25% hydrogen peroxide gel. Zoom! Take-Home Gel is available in 4% or 6% hydrogen peroxide. Day White is 7.5% hydrogen peroxide. Activation Unit/Mode Light activation. The light consists of a five-legged base, a stationary vertical arm that supports the control box, and an adjustable horizontal arm, the end of which holds the lamp. The predominant color of the entire unit is white, giving it a clean, contemporary look. Since there are no casters on the base, the size (vertical arm is 45.0in/114.3cm in length, the horizontal arm attachment measures 29.0in/73.7cm in length) and weight (21.0lb/9.5kg) makes transporting this light quite cumbersome. The cylinder-like control box, measuring 12.5in/31.8cm in length x 5.25in/13.3cm in width x 4.25in/10.8cm in depth, ©2005 REALITY Publishing Co. Vol. 19 Discus www.discusdental.com includes a small LCD screen plus soft-touch switches, one for turning the unit on-off (begins the warm-up), while the other actually activates the timer and allows you to pause the timer (although the light stays on). The bleaching time has a default interval of 20 minutes. The actual lamp, also cylinder-like with a silver oval accent design on top, has the name of the product embossed in a classy touch. The front of the lamp (facing the patient) also has the name of the product embossed in white, the aperture for the beam of light itself, and round receptacles on either side of the aperture. The overall appearance is very sleek and futuristiclooking, sort of reminiscent of the Jetson’s type of décor. The lamp measures 13.0in/33.0cm in length. Utilizing a short-arc metal halide bulb, the lamp emits ultraviolet light (UVA) through the rectangular aperture, which measures 0.75in/1.9cm x 2.15in/5.5cm. The round receptacles stabilize the rod-like guides, which establish the correct position of the light in relation to the mouth. In order to use the light, the fuse, which comes in a separated envelope, must be installed. To do this, you open the small receptacle on the bottom surface of the control box and insert the fuse. This is an easy and quick operation. The Ratings 59 Bleaching Materials Radiometer Solarmeter. Digital ultraviolet radiometer that resembles a garage door opener. Measuring approximately 4.0in/10.2cm x 2.4in/6.0cm x 0.8in/2.1cm and weighing 4.0oz/113.4g, you merely activate the light for a few minutes, hold the radiometer against the light aperture, hold the small button on top of the radiometer, and read the light’s power on the radiometer’s LCD screen. Originally, any reading over 50 was supposed to be adequate. However, while one of our one-year-old units tested at 84, a new unit tested only at 48, while another one-year-old unit only scored 33. Discus now states that its tests show even readings as low as 20 will not affect bleaching efficacy. Changing the Bulb Entire lamphead must be replaced by Discus representative. ture. Be sure to wait for five minutes after taking the syringe out of the water before extruding the gel. After placing the retractor, secure the bib (looks like a rubber dam napkin), which further protects the surrounding tissue from the bleach and ultraviolet light. Activate the light, which requires a three minute warm-up cycle before the actual whitening cycle can begin. The unit will beep once as the timer approaches the final three seconds of the three minute warm-up cycle. Once the light is turned on, do not attempt to turn it off or disconnect the power for a minimum of 60 seconds. Doing so will harm the bulb and void the warranty. Recommended Total Bleaching Time (Per Appointment) 60 minutes. Approximate Length of Appointment (includes actual bleaching time, isolation procedures, polishing before bleaching, light warm-up and cooldown times, removal of isolation at end, etc.) 105 minutes. Initial Clinical Evaluation Shade Changes One Month 5.5 Three Months 5.1 Consistency and Handling 5.0 Mixing tip automatically incorporates the ingredients in the dual-barrel syringe to produce a viscosity that has just enough flow to apply easily to teeth, but is not runny. Be sure to dispense initially on a pad, since the beginning of each syringe tends to be on the watery side. Once the viscosity turns more gel-like, it is ready for application on the teeth. 0 1 2 3 MOST FLOW 4 5 LEAST FLOW pH 8.9 Soft Tissue Protection Liquidam. Blue, light-cured resin. Dispensed directly on the tissue from its syringe. Liquidam is a viscous liquid and can be applied one quadrant at a time for greater control. Use Swab the lips with a coat of the 30 SPF protective lip cream, which shields the patient from the ultraviolet light. Remove the syringe from the refrigerator at least six hours before use or preferably the previous evening. If you forget and the syringe is removed immediately prior to the appointment, place it in a cup of hot tap water (120°F/49°C) for 10 minutes to bring it to room tempera- 60 The Ratings During the light warm-up period, apply the whitening gel directly from the syringe, using a disposable brush to spread the gel completely over the facial surfaces of the teeth. Then place the light guides, which have rectangular foam bite blocks for positioning interocclusally in the molar area and plastic posts, into the receptacles in the face of the light. Posts should extend out along the edge of the cheek retractor. When assembled properly, the light should rest 1.5in/3.8cm from the facial surfaces of the maxillary central incisors, although our measurements were closer to 2.0in/4.4cm. While this positioning doesn’t sound complicated, it is not as straightforward as it may seem. Having four hands definitely helps. By now, the warming time has expired and you can activate the light for 20 minutes. When the 20 minutes has expired (you are alerted with a beep three minutes before the end of the 20 minutes and then again by three beeps starting three seconds before the end of the 20 minutes), move the light away from the patient and wipe off the gel. The light will automatically turn off and go into the cooldown period, which lasts for two minutes. At the end of cooldown, the fan cooling the light goes off, but there is no beep, alerting you to manually begin the warm-up period again. Repeat the bleaching procedure two more times. Sensitivity (as determined during our clinical evaluation) During the Procedure None. Post-Operative Two patients in the initial evaluation and one patient in the follow-up evaluation reported slight sensitivity within the first 24 hours of treatment, while the others had none. Desensitization 1.1% neutral sodium fluoride for five minutes. ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Packaging The Procedure Kits come in a clear plastic tray with a cardboard insert acting as a lid. The tray contains all materials except for retractors and the bleach itself, the latter of which is in a separate cardboard box that needs to be refrigerated. Expiration sticker is on the bottom of the Procedure Kit tray and side of the cardboard box holding the bleach. Directions Coated paper booklet with step-by-step instructions accompanied by color clinical photos. Easy to understand and follow. PostWhitening Care Instructions are on a separate card. There are also two professionally-made instructional videos (also available on CD) that are very well done. One of them is very comprehensive and even covers assembling the light, while the other is truncated and gets more quickly into the technique. Marketing Materials Most of the new approach leverages on Zoom! being used on the Extreme Makeover TV show and feature Dr. William Dorfman, the founder of Discus. Among the various materials available are appointment/postcards, statement stuffers, brochures, brochure holder, posters, counter cards, buttons, baseball caps, window stickers, etc. Brochures are well-done with Q&A format, but states the process takes “just over an hour” when there is no way you’ll be finished in less than 1.5 hours. Opalescence Xtra Boost Ultradent (4.0) www.ultradent.com 2a Intro Kit Cost: $99.99 ($20.82/ml) Includes: • 4 syringes of Opalescence Xtra Boost (0.96ml ea) • 4 syringes of Activator (0.24ml ea) • 2 syringes of OpalDam (1.2ml ea) • 10 Micro 20 delivery tips • 10 Micro 22 FX delivery tips • 2 IsoBlocks • Total bleaching material = 4.8ml Cost/patient/appt = $67.90 (4 dual syringes and 1 syringe of OpalDam) Refills: Cost: $29.99 Includes: • 2 syringes of Opalescence Xtra Boost (0.96ml) • 2 syringes of Activator (0.24ml) Shelf Life: 1.5 years (refrigerated) MSDS: Included Composition of Bleach 38% hydrogen peroxide gel. Activation Unit/Mode Chemical activation. The syringe of regular Opalescence Xtra is “boosted” by mixing with a proprietary chemical activator. This mixing is done by linking the two syringes via a Luer-lock-type of connection. Recommended Total Bleaching Time (Per Appointment) 60-90 minutes. ©2005 REALITY Publishing Co. Vol. 19 Does not require a light Color makes applying even layer easy No retractors in kit Mixing is tricky Approximate Length of Appointment (includes actual bleaching time, isolation procedures, polishing before bleaching, removal of isolation at end, etc.) 90-120 minutes. Initial Clinical Evaluation Shade Changes One Month 3.0 Three Months 2.7 The Ratings 61 Bleaching Materials Consistency and Handling 5.0 Remove the syringe tips and attach the ends of the syringes via the Luer-lock connectors. Then push the contents of one syringe into the other, followed by the reverse motion 10-12 times to thoroughly mix the two materials. The mixture will end up in the red Boost syringe, which is used to deliver the material to the teeth. Viscosity has just enough flow to apply easily to teeth, but is not runny. 0 1 2 3 MOST FLOW 4 5 LEAST FLOW Sensitivity (as determined during our clinical evaluation) During the Procedure None in the initial evaluation. In the follow-up evaluation, one patient was slightly sensitive, while another described the discomfort as “throbbing”. Post-Operative In the initial evaluation, three patients had slight sensitivity, one patient had moderate sensitivity, and one patient, the only one having mandibular bleaching, had severe sensitivity and had to take pain medication. In the follow-up evaluation, one patient had slight sensitivity, while two patients had severe sensitivity and had to take pain medication. One of these latter patients had mandibular bleaching. pH 7.6 Desensitization UltraEZ (not included in kit) used in a tray at home. Soft Tissue Protection OpalDam. White, light-cured resin, with filler that sparkles. Dispensed directly on the tissue from its syringe. Due to its runny consistency, you need to cure for a few seconds as you place it around each tooth. If you try to apply to more than one tooth before curing, it will flow over the tooth, requiring you to chip off the excess using a #15 scalpel. This is time-consuming and a nuisance, since it sets very hard. Packaging Clear, plastic box with an attached, side-opening lid. Removable, clear plastic tray secures and organizes the contents. Nice, neat, and convenient. Xtra Boost syringes are clear red plastic, while the Activator is in a clear plastic syringe with a red plunger and cap. OpalDam syringes are blue with white plungers. Expiration date is embossed on the syringes, but you need the secret code to decipher it. Use After mixing, apply the material directly from the syringe for 1015 minutes, agitating the mixture every five minutes. At the end of the 10-15 minutes, suction the excess with a surgical aspirator tip. Do not rinse. Then re-apply up to five more times in 10-15 minute intervals for a maximum total of six applications. Make sure you use a new syringe tip with each newly mixed syringe. Directions Plain paper, two-sided fold-out. On one side, there is a summary of the technique in 19 languages with seven small, black and white photos. On the other side, there is a more detailed version with larger photos. Good advice, easy to follow. A note in bold states that the activator and the bleach must never be used separately. Always mix. On the backside, instructions also state that after mixing, the product is good for 10 days. Marketing Materials Only one poster and one statement stuffer. See Opalescence (Home Bleach) for other, more generic marketing materials. 62 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Opalescence Xtra Ultradent (4.0) 2b Cost: $79.99 ($16.66/ml) Includes: • 4 syringes of Opalescence Xtra (1.2ml ea) $55.99/4 ($11.46/ml) • 2 syringes of OpalDam (1.2ml ea) Shelf life: $32.99/4 ($6.87/ml) 1 year refrigerated • 20 Micro 20 Tips • 20 Black Mini Tips MSDS: Included • 2 IsoBlocks • Total bleaching material = 4.8ml Cost/patient/appt = $63.00 (4 syringes and 1 syringe of OpalDam) Composition 35% hydrogen peroxide premixed gel containing carotene, which gives it the bright orange color. Activation Unit/Mode None supplied but use of a light is optional. If you choose to use a light, you should use the largest tip, at least 11mm, and keep it as close to each tooth as possible. Carotene presumably absorbs light to activate the peroxide. Recommended Total Bleaching Time (Per Appointment) 45 minutes. Approximate Length of Appointment (includes actual bleaching time, isolation procedures, polishing before bleaching, removal of isolation at end, etc.) 75 minutes. Initial Clinical Evaluation Shade Changes One Month N/A Three Months N/A Consistency and Handling 5.0 Easy to dispense gel, slightly runny. 0 MOST FLOW 1 2 3 4 5 Carrots for bleaching Easy to apply More sensitivity than others Why not broccoli? the excess using a #15 scalpel. This is time-consuming and a nuisance, since it sets very hard. Adding some flexibility into the resin may be an improvement. Once you finish the arch, cure for an additional 20 seconds, although the heat produced by curing can cause discomfort. Use Apply directly from the syringe, cover the teeth with at least a 1.0mm thick layer of gel, and light activate each tooth 20-30 seconds with a halogen light or 3-5 seconds with a plasma arc light. However, this is only valid if your plasma arc light has a large tip and it provides the full power of the light. From our tests (see CURING LIGHTS), no plasma arc can achieve this feat. Therefore, if you hold the light away from the tooth to expose the entire facial surface, you probably want to increase the exposure time to 10 seconds. After 10-15 minutes, suction the gel and rinse well. If no sensitivity, repeat the process. Sensitivity Minimal when no-heat is used. There was slight sensitivity with the light-activated side. Desensitization UltraEZ (not included in kit) used in a tray at home. Packaging Cardboard box with an attached, side-opening lid. Removable, white plastic tray secures and organizes the contents. Nice, neat, and convenient. Xtra syringes are clear red plastic while OpalDam has blue syringes with white plungers. The expiration date is on a sticker on the bottom of the box and is also engraved into the individual syringes near the finger rest, but it is very difficult to read. LEAST FLOW pH 4.3 Soft Tissue Protection OpalDam. White, light-cured resin, with filler that sparkles. Dispensed directly on the tissue from its syringe. Due to its runny consistency, you need to cure for a few seconds as you place it around each tooth. If you try to apply to more than one tooth before curing, it will flow over the tooth, requiring you to chip off ©2005 REALITY Publishing Co. Vol. 19 Directions Six-page, newsletter-like pamphlet on coated paper with clinical photos. Good detail, including the technique with both OpalDam and the rubber dam. In addition, there is a single sheet of coated paper in 13 languages. Features color illustrations showing the application steps. Marketing Materials Only with Xtra Boost. See Opalescence (Home Bleach) for other, more generic marketing materials. The Ratings 63 Bleaching Materials 3 Niveous Shofu (3.6) www.shofu.com NEW Cost: $184.95 ($18.50/ml/ampule) Includes: • 10 ampules of Niveous (1.0ml ea) $269.95/25 ($10.80/ml/ampule) • 1 syringe of Liquid Dam (3g/3ml) $25.95/2 ($4.33/ml) • 10 Liquid Dam Tips • 30 Booster Brushes $38.95/100 ($0.39 ea) • Total bleaching material = 10.0ml Cost/patient/appt = $96.97 (8 ampules, 16 Booster Brushes, and 1/3 syringe of Liquid Dam) Shelf life: 1 year refrigerated MSDS: Not included Ampules dispensing Easy to apply Booster Brushes don’t activate gel equally Not as effective as others Consistency and Handling 0.0-5.0 Depends on its temperature. When the gel is warm and the treatment room is not overly cooled by air conditioning, it is not runny. But if either the gel and/or the room is very cool, it can be very runny. 0 1 2 3 4 5 MOST FLOW Composition 27% hydrogen peroxide premixed gel containing orange pigment. Activation Unit/Mode Booster Brushes, which are impregnated with a proprietary oxidizing chemical. A light is not part of the system, but you may still choose to use one. Recommended Total Bleaching Time (Per Appointment) 30 minutes with light. 45 minutes without light. Approximate Length of Appointment (includes actual bleaching time, isolation procedures, polishing before bleaching, removal of isolation at end, etc.) 60-75 minutes. Clinical Evaluation Shade Changes One Month N/A Three Months N/A 64 The Ratings pH Before activation After activation LEAST FLOW 3.6 3.6 Soft Tissue Protection Liquid Dam. Blue, light-cured resin. Dispensed directly on the tissue from its syringe. Good consistency—allows application to the tissue around a quadrant without flowing over the teeth, yet it has good affinity for the tissue for sealing purposes. Light cure for 20 seconds—the mild heat produced should cause only slight discomfort. Even though Liquid Dam is supplied, the rubber dam is also recommended. Use Make sure the ampule has been removed from the refrigerator several hours before using. Even then, it is prudent to put the ampule in warm water for 30 seconds before dispensing. If the material is cold, it can be very runny. Cut the sealed end of an ampule and apply the bleach directly onto the teeth, covering them with at least a 1.0mm thick layer of gel. Then activate the bleach by agitating it on each tooth for 15 seconds with a Booster Brush. The material will start bubbling on the teeth, presumably indicating that the oxidation program has begun. Alternatively, you can dispense the bleaching gel into a ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials dappen dish (the dish that comes with the kit is too small), stir the bleach with 2-3 Booster Brushes for activation, and apply to the teeth. One ampule is necessary for each arch. Note that, even though the warmed gel is very thick when initially dispensed, it tends to become runny duration the activation process, which requires stirring the gel with the brushes. If you choose to use a halogen light, each tooth should be exposed to the light for two minutes. With a plasma arc light, exposure time is supposed to be only five seconds per tooth. However, this is only valid if your plasma arc light has a large tip and it provides the full power of the light. From our tests (see CURING LIGHTS), no plasma arc can achieve this feat. Therefore, if you hold the light away from the tooth to expose the entire facial surface, you probably want to increase the exposure time to 10 seconds. After 15 minutes, suction the gel and rinse well. If no sensitivity, repeat the process 2-3 times, using a newly activated mix of bleach for each application. Sensitivity (as determined during our clinical evaluation) During the Procedure None. Post-Operative One patient had slight sensitivity, which was resolved using Sensodyne toothpaste. Desensitization Not provided or recommended. Packaging Cardboard box with a rear-attached lid. Removable, white plastic tray secures and nicely organizes the contents. Ampules are clear soft plastic while Liquid Dam is in a conventional black, pushtype syringe. There is a space on the side of the box for the expiration date, but the date was missing. Directions 10-page, coated paper booklet with seven drawings to aid with application specifics. There is also a quick reference guide inside the lid of the box. Information is straightforward and easy to understand. However, the booklet tells you to remove the bleach from the refrigerator at least 15 minutes before use, while the instructions inside the lid states 2-3 minutes is sufficient. In addition, the instructions inside the lid tell you to apply twice for 15 minutes each, but then it is stated that “optimal results may be achieved with less applications”. If the standard is two applications, then the only less option is one application. We find it difficult to believe that one application will give you “optimal results”. Marketing Materials Only a brochure, although it is well-done and should appeal to a wide variety of patients. Features a head and shoulders shot of a young woman on the cover and a before and after smile shot inside. Only flaw is the copy on the cover that states “Just smile, baby!”, which smacks of Austin Powers slang. A more sophisticated message would be better. REALITY Zoom! gives you the biggest bang for your buck when it comes to the light, not to mention its ultracool appearance. Its marketing support is also unrivaled. However, it’s the most difficult of the lights to position properly, the lack of casters makes moving it from room to room a chore, and tissue protection is most critical due to its ultraviolet lamp. Nevertheless, its procedure kits are the most complete in this category. In the initial evaluation, it produced an average three-month clinical shade change of 5.1 (the most), which was confirmed in the follow-up evaluation. Opalescence Xtra Boost uses a unique twin-syringe system for activation, but be sure to mix it thoroughly using the conjoined syringes and apply it sparingly or your price per application will rise. All of the patients had post-treatment sensitivity of some sort and it produced an average three-month clinical shade change of 2.7 (the lowest) in the initial evaluation. The follow-up evaluation had slightly better results. Opalescence Xtra is the least expensive and the only product in this group with conveniently premixed gel, which is dispensed directly from its syringes onto the teeth. While it ©2005 REALITY Publishing Co. Vol. 19 was not included in the initial evaluation, the follow-up evaluation found about the same results as its stablemate, Xtra Boost. It seemed to be more likely to cause sensitivity than the other products. Niveous is, perhaps, the most innovative product in this group, with its bleach activation being impregnated into the fibers of the applicators that come with the kit. Its unidose ampules also make the packaging and dispensing more calibrated. However, the bleaching times and technique recommended are not effective and are hard to decipher. The bleaching time of 30 minutes or less is just not realistic. To get any kind of results with this product, we strongly recommend a full 60 minutes of bleaching. Then you need to consider the kit and calculating how much bleach and how many Booster Brushes to use. It comes with 10 ampules of bleach and 30 Booster Brushes. This presumably means that you are supposed to use three brushes to activate each ampule. But the instructions state that you should use one brush for six teeth and, since it appears you The Ratings 65 Bleaching Materials should use three brushes for each ampule, then each ampule should bleach 18 teeth. However, we found one ampule only has enough bleach to cover 10 teeth in a typical maxillary arch, with virtually no gel available for the mandibular arch. Since you are supposed to use one brush for six teeth and we were bleaching 10 teeth, we settled on using two brushes to activate each ampule. (Our activation test did not show any greater “bubbling” effect using three as compared to two brushes.) Note: We chose to activate the bleach in a dappen dish as opposed to applying it to the teeth and then activating it, since we reasoned that in the latter method, the teeth exposed to the brushes first would get a high concentration of the activation material embedded in the fibers, while the end of the line teeth would be shortchanged. By activating the bleach in a dappen dish, we assumed each tooth would get the same activation level of bleach. The clinical evaluation showed results similar to the Xtra twins. Assisted Bleaches Although there are several home bleaching products at the 30% carbamide peroxide level, these products continue to be marketed, despite the fact that they typically contain 35% carbamide peroxide or its equivalent, which, of course, is only slightly higher than the at-home products. Originally used as a first-appointment booster for a home bleaching program, these products were not necessarily promoted as a stand-alone office bleach. This is due to the fact that carbamide peroxide is not as strong as hydrogen peroxide. Therefore, you would not expect to get the same results from these products as compared to the hydrogen peroxide gels. We found these materials were able to produce a slight change in shade after one 30-minute bleaching session, with their efficacy virtually the same. It is clear their real contribution could be as high-powered home bleaches for patients who do not have any pretreatment sensitivity and want the absolutely fastest results. With this impending dispensing change, direct application without a tray would seem to be a time-consuming, labor-intensive, unnecessary option. A more logical approach would have the patient fill and wear the tray for the first session in the office. Assuming the patient does not experience any untoward effects, the patient would then take the bleach with him or her and continue an abbreviated home bleaching schedule. Be careful not to overlap the gingiva with the bleaching tray to keep these products off the soft tissue. Even though they are not as caustic as high concentration hydrogen peroxide gels, these products do have the capability to irritate the gingiva. Opalescence Quick 1a Ultradent (3.9) Cost: $23.99 ($5.00/ml) Includes: • 4 syringes of gel (1.2ml ea) $103.99/20 ($4.33/ml) • 4 White Mac tips • Total bleaching material = 4.8ml Shelf life: 2 years refrigerated MSDS: Included Easy dispensing Good viscosity Is it really necessary to warm before using? Can cause soft tissue soreness quickly if excess is not removed immediately after seating tray Concentration 35% carbamide peroxide. Consistency and Handling 5.0 Thick viscosity gel, easy to control and wipe off gingiva. 0 1 2 3 MOST FLOW 66 4 5 LEAST FLOW The Ratings Flavor One: Neutral—no specific flvaor. pH 6.1 ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Use Only bleaching tray method recommended. It is suggested to hold syringe under hot water for 2-3 minutes to warm bleach, which seemed to slightly enhance bleaching effect and did not cause any pain. Sensitivity None reported, although it can cause gingival soreness fairly rapidly if excess is not removed from soft tissue. Packaging Small, clear plastic tray with clear plastic lid. Clear syringes with gold plungers, and includes Straight Mac tips. Depending on the size of the bleaching tray, each syringe contains enough bleach for one or two arches. The expiration date is on a sticker on the label of the box, and is also chiseled on the syringe itself near the finger rest (very difficult to read). Certified Kosher-Pareve by Rabbi Benny Zippel of the Chabad Lubavitch of Utah. So, you can now feel free to bleach regardless of whether you have eaten meat or dairy! Directions Small coated paper foldout with nine color photos and one color illustration. Easy to understand and follow. Also has the Kosher seal! White Speed Discus (3.9) 1b Cost: $50.00 ($6.94/ml) Includes: • 2 dual-barrel syringes (4g/3.6ml ea) • 12 syringe tips • Total bleaching material = 8g/7.2ml Shelf life: 2 years Why mix the two peroxides? Tends to foam inside tray and run down the throat MSDS: Not included Concentration 19% hydrogen peroxide and 20% carbamide peroxide. After mixing, is the equivalent of 35% carbamide peroxide. Consistency and Handling 4.5 Medium-thick viscosity gel, slightly runny, but easy to control and wipe off gingiva. 0 MOST FLOW 1 2 3 Great name Cool syringe 4 4.5 5 LEAST FLOW Flavor One: Peppermint Cream. Described as “delicious”, but more like tolerable. Sensitivity Very minimal. Packaging Clear plastic tray with flip-up, cardboard lid holding the two dualbarrel syringes, translucent purple barrels and gray/green plungers. Barrels have 12 calibrations, which are supposed to correspond with an equal number of applications, but our test found you will probably only be able to fill 3-4 trays with one syringe. And mounting the tips on the syringes can be tricky. Directions Inside lid of plastic tray. Short, to the point. pH 5.6 Use Only bleaching tray method recommended. ©2005 REALITY Publishing Co. Vol. 19 The Ratings 67 Bleaching Materials Polazing 2 SDI (3.8) Cost: $25.00 ($4.81/ml) Includes: • 4 syringes of gel (1.3g/1.3ml ea) • 4 tips • Total bleaching material = 5.2ml Shelf life: 2 years, 3 years refrigerated MSDS: Not included Concentration 35% carbamide peroxide. Also includes fluoride, proprietary desensitizing agent, and Chitosan, which is a polysaccharide found in the exoskeleton of shrimp and crabs and is chemically similar to cellulose. If your patient is allergic to shellfish, you may want to use another product. It presumably acts as a natural soother and conditioner that inhibits plaque formation and aids in calcium absorption to further reduce sensitivity and ion loss from enamel. Consistency and Handling 5.0 Thick viscosity gel, easy to control and wipe off gingiva. 0 1 2 3 4 MOST FLOW 5 LEAST FLOW Flavor One: Mint, but it is very subtle. Easy dispensing Good viscosity Wrong instructions in kit Do you really want a bleach with “zing” in its name? Sensitivity None reported. Packaging Small, cardboard box with removable white plastic tray securing the syringes. Clear syringes with clear plungers need you to install tips. Depending on the size of the bleaching tray, each syringe contains enough bleach for 2-3 arches. The expiration date is on a sticker on the bottom of the box and is also imprinted on the syringe itself. Directions Plain paper foldout in seven languages. Composition listed doesn’t correlate with marketing materials, since there is no mention of a desensitizer or Chitosan. No photos. There is also the same plastic-laminated card that is found in the Poladay kit, but the card is for patients, who are not supposed to be self-bleaching with this product. pH 5.5 Use Only bleaching tray method recommended. REALITY Opalescence Quick has those terrific Ultradent syringes, which makes it the easiest to dispense the gel into a tray. However, be sure to remove the excess from the soft tissue immediately after seating the tray—it can cause discomfort quite quickly otherwise. White Speed, mixing two different peroxides to arrive at the same concentration of carbamide peroxide and its dualbarrel syringe with miniature mixing tip, at least creates some intrigue. However, the mixture tends to foam up intraorally and can run down the patient’s throat. Polazing is easy to dispense and does not seem to cause sensitivity, but who wants to “zing” a patient during bleaching? 68 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Home Bleaches These products contain various concentrations of carbamide peroxide or hydrogen peroxide. While most versions keep the concentration at 22% carbamide or lower, home bleaches with 30% carbamide peroxide are now being sold, although this concentration is still considered quite high by most dentists. Nevertheless, the trend is to use stronger bleaches for shorter periods of time. Even Crest Whitestrips, which Proctor & Gamble has chosen not to submit for evaluation, has a “supreme” version that contains 14% hydrogen peroxide (equal to about 42% carbamide), although the marketing adds “some people may experience sensitivity”! Other differences between the products are based on viscosity, flavor, packaging, and marketing. And all of them have the potential to cause gingival inflammation and/or tooth sensitivity if not used properly. Composition Carbamide peroxide is the main ingredient for most home bleaches, but hydrogen peroxide is thought to be more active. While we have indicated which form of peroxide each product contains, most of the independent research plus our evaluator ratings have failed to find any significant differences between them. Concentration For carbamide peroxide products, the range is from 10% to 30%. It would seem the higher the percentage, the more effective the material. However, there are other factors such as the viscosity, which seem to be just as important as concentration. For hydrogen peroxide products, 3.0% to 9.5% is the range. pH Has been implicated in causing sensitivity. It follows, therefore, that a more neutral pH bleach would be less likely to cause sensitivity. Viscosity Thicker and stickier is usually better. The more adherent the bleach is to teeth, the more effective it probably is and the easier it is to keep it off the soft tissue and from flowing down the throat. On the other hand, those extra sticky bleaches are sometimes difficult to remove, especially from embrasures. Packaging Convenience is a major item in this category, since patients will only use the bleach if it is easy and not a hassle. All of our CHOICES are offered in individual syringes, which can be given to patients a few at a time. This effectively forces patients to return to the office on a regular basis (as often as you feel necessary) to have their teeth and tissues checked. Several of the manufacturers also include their toothpastes and mouthrinses in these kits. One evaluator felt toothpaste and mouthrinse do not belong in this type of kit while other evaluators reported that patients appreciated these extra components. ©2005 REALITY Publishing Co. Vol. 19 Bleaching Tray Material Most of the bleaches come with material for bleaching trays. All of these tray materials are very flexible and comfortable. We tested each manufacturer’s tray material for ease of fabrication and thickness. There are also different names given for bleaching trays, ranging from nightguards, mouthguards, whitening trays, application trays, and mouth splints. The only one from that group that really describes its purpose is whitening tray. We continue to favor bleaching tray, since most of the public refers to tooth whitening as bleaching. Reservoir Material These are applied to the facial surfaces of teeth on the patient’s model prior to making the tray. It provides a narrow space (about 1.0mm) between the teeth and the bleaching tray. This space presumably allows more bleaching gel to stay in contact with the teeth. Our own clinical study showed there were no differences in bleaching, regardless of whether a reservoir was used or not. Therefore, we do not recommend reservoirs in bleaching trays. We have left this information in each product’s commentary, just in case you choose to continue using reservoirs. Some of these products also have other uses. Please see BLOCK-OUT RESINS for more information. Storage Most manufacturers of peroxide products, regardless of whether they are destined for office or home use, recommend refrigeration until they are dispensed. This means you should tell your patients to keep their bleach in the refrigerator when they are home and not to leave the bleach or their bleaching tray in their car when the weather is warm or hot. They should be active for one year if refrigerated. In addition, none of these home bleaches require an MSDS. The Ratings 69 Bleaching Materials Opalescence/Opalescence PF 1 REALITY’S Ultradent CHOICES www.ultradent.com (4.5) Cost: $35.99 ($2.50/ml) Doctor Kit Includes: • 12 syringes of gel (1.2ml ea) • 2 Sof-Tray sheets • 1 tray case • 1 syringe of LC Block-Out (1.2ml) • 1 tube of Opalescence toothpaste (1oz) • Shade Guide Card • Total bleaching material = 14.4ml Refills: Cost: $103.99 ($2.17/ml) Includes: • 10 kits (4 syringes/kit) • 2 Shade Guide Cards • Total bleaching material = 48ml Shelf life: 2 years refrigerated Single dose syringes are still the easiest Very good marketing support Stronger than 20% would be nice Sharp edges on plastic boxes are not friendly Composition Opalescence carbamide peroxide. Opalescence PF carbamide peroxide, 0.11% fluoride ion, and 3% potassium nitrate. Concentrations Opalescence 10%. Opalescence PF 10%, 15%, and 20%. Color Clear. Consistency and Handling 5.0 Very thick, sticky viscosity, helps to keep gel in contact with the teeth. 0 1 2 3 4 MOST FLOW pH 6.3-6.6 Flavors Three: regular, mint, and melon. 70 5 LEAST FLOW The Ratings Packaging The kit is a translucent plastic box with a removable plastic tray securing the contents. The color accent on the plastic instantly identifies the flavor: purple is regular, green is mint, and pink/peach is melon. However, if you are not familiar with the color-coding, there is no other flavor identification on the box. This box has a contemporary look, but the sharp corners of the plastic are uncomfortable during opening. Inside, there is a clear plastic insert securing the tray case and the tube of Opalescence toothpaste. The syringes of bleach are secured in translucent plastic trays, four syringes to a tray. A slide-off sleeve serves as a cover for the syringes. The refill boxes contain 10 of these 4-syringe trays (also available as 2-syringe trays). A box can be quickly retrieved through a cutout on the side. However, the sleeve also has no flavor designation other than the color-coding. The tray case has a very low profile and can fit into a pocket or purse without much bulk. Attractively embossed with the Ultradent logo, it is made out of translucent plastic that is colorcoded with the rest of the kit. The syringes have the tips already attached. The direct imprinting on the syringes prominently indicates the concentration and flavor of the gel. In addition, the syringes for each flavor and concentration have different color imprinting, plastic barrels, and/or plungers. These syringes are smaller than those of the other materials in this category, with each syringe containing enough material to fill the bleaching tray once if you are bleaching the entire arch (first molar to first molar) or twice if you are bleaching less teeth and the teeth are small. This smaller syringe has both advantages and disadvantages. Its advantages include very easy dispensing for patients and you. Patients do not have to worry about looking at lines on the ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials syringe to make sure they are using the appropriate amount — they just fill the tray with the syringe and throw it away. For you, there is less calculating how many syringes to give the patient. If you want them to fill and wear the bleaching tray twice a day, you give them two syringes for each day. You don’t even need a calculator! The main disadvantage is adding more plastic to our landfills and you need to give the patient more syringes. The expiration date is on a label on the side of the main box, and is also chiseled into the syringe itself (although very difficult to read). Bleaching Tray Material Brand name: Sof-Tray. Before fabrication: 0.7mm thick. After vacuum-forming, was 0.5mm thick in the middle of the facial surface of the maxillary left central incisor. Slightly larger dimensions compared to the other tray materials tend to keep it more secure in the vacuum-forming machine when it is brought down over the model. It also does not shrink when heated in a vacuum-forming machine. Reservoir Material Brand name: LC Block-Out. Blue, easy to apply. Directions Dentist Plain paper foldout in 19 languages with b & w photos. Fairly comprehensive in English, covering pre-treatment procedures, tray fabrication, and general information. Patient Plain paper foldout in 19 languages with b & w photos. But there is a General Precautions areas that is written more for the dentist than the patient. Wisely advises following the dentist’s recommended bleaching protocol. Marketing Materials BluePrints for Success is a comprehensive marketing program that fits into a three-ring binder (not provided). It covers advertising, public relations, and a media kit. Excellent information and easy to follow. There are also postcards, counter displays, statement stuffers, and posters, with several different themes including season-specific. Day White Excel 3 Discus (4.3) www.discusdental.com 2a Cost: $36.00 ($2.50/ml) Standard Kit Includes: • 6 dual-barrel syringes of gel (2.6g/2.4ml ea) • Bleaching tray case • 6 automix syringe tips • Total bleaching material = 14.4ml Cost: $15.50 ($2.15/ml) Mini Kit Includes: • 3 dual-barrel syringes • 3 automixing tips • Total bleaching material = 7.2ml Shelf life: 2 years Concentrations 7.5% and 9.5%. Gives daytime bleaching an identity Using the real stuff makes sense Can’t you use any bleach during the day? Is there really an advantage of hydrogen over carbamide? Composition Hydrogen peroxide. Activator contains eugenol, xylitol, and aloe vera. ©2005 REALITY Publishing Co. Vol. 19 Color Clear. Consistency and Handling 5.0 Very thick. Very easy and precise dispensing into tray, although one evaluator thought it was too foamy. 0 MOST FLOW 1 2 3 4 5 LEAST FLOW The Ratings 71 Bleaching Materials pH 8.6-9.5 All the kits and syringes are prominently marked as to their concentration of hydrogen peroxide. The syringes are all identified as DAY WHITE Excel 3, with fuchsia printing for 7.5% and gold printing for 9.5%. The expiration date is on a label on the bottom or side of each box. Flavor One: Cool mint. Packaging Standard kit has a contemporary white cardboard with removable lid that opens to reveal a translucent turquoise plastic tray securing six dual-barrel syringes of material, automix tips, and a case for the bleaching trays. There is an opening in the middle of the lid that exposes the two-syringe cases that are placed on top of one another inside a recess in the box. The tray case is a sleek, expensive-looking, semi-translucent turquoise retainer-like box with an unusual surface finish and Discus Dental embossed on the bottom. The six dual-barrel syringes are arranged in groups of three in separate plastic translucent turquoise cases that are stacked on top of each other. There are recesses inside each of the plastic cases that secure three syringes and three tips. The inside of the box lid contains some general instructions for the patient. The syringes have been imprinted with six calibrations, guiding the patient as to the amount of bleaching gel to be dispensed into the bleaching tray. This means each syringe should be able to fill a bleaching tray six times, although on the average, most patients were able to get only four doses per syringe. The Mini kit comes in a thin white cardboard box with a sideopening flap. The three syringes come in the same translucent turquoise plastic case that is in the standard kit, and an opening in the top of the box showcases the cover of the plastic case. Patient instructions are printed on the bottom of the cardboard box. This Mini kit gives you a convenient and attractive package to give to patients when they want to do a touchup, although there is also a kit called the Single Kit that just contains one syringe. 2b Bleaching Tray Material Before fabrication: 1.0mm thick. After vacuum-forming, was 0.4mm thick in the middle of the facial surface of the maxillary left central incisor. Reservoir Material Not recommended. Directions Dentist None in the kit, but there is a double-sided postcard with four color illustrations on how to fabricate a bleaching tray in the bag holding the tray material. Straightforward and easy to understand. However, it is suggested to use Splash Lite Body for the bleaching tray impression, even though this low viscosity material has excessive flow for placement in an impression tray and is not as effective as a higher viscosity material. Patient Small glossy booklet with two photos, placed under the stacked two-syringe packages. It is generic in that it applies to both Day White and Nite White. Gives good advice on handling sensitivity, but recommends wearing the tray for a maximum of one hour at a time. However, we prefer that manufacturers leave the bleaching protocol to each dentist’s discretion. Marketing Materials Nothing specific for this product. Multitude of materials for bleaching in general and other products. Nite White Excel 3 Turbo Discus (4.3) www.discusdental.com NEW Cost: $39.00 ($5.65/ml) 3-syringe Kit Includes: • 3 dual-barrel syringes of gel (2.4g/2.3ml ea) • Bleaching tray case • 3 automixing syringe tips • Total bleaching material = 6.9ml Cost: $28.00 ($6.09/ml) 2-syringe Kit Includes: • 2 dual-barrel syringes (2.4g/2.3ml ea) • 2 automixing tips • Total bleaching material = 4.6ml Shelf Life: 1 year 72 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials If you want thick, this is it Could this be the first sensitivity-free bleach? Difficult to remove from embrasures White color does not permit discrete bleaching Composition Hydrogen peroxide and potassium nitrate. Concentration 6%. Bleaching Tray Material Before fabrication: 1.0mm thick. After vacuum-forming, was 0.4mm thick in the middle of the facial surface of the maxillary left central incisor. Color White. Consistency and Handling 5.0 Very thick. Very easy and precise dispensing into tray. Adheres exceedingly well to teeth. When a tray is removed, half of the bleach remains on the teeth. And, if your patients have open gingival embrasures, this material will not rinse off even with aggressive rinsing—they must use a toothbrush and/or floss. In addition, mixed material was not always homogeneous. 0 MOST FLOW a minimum of excess. This means each syringe should be able to fill a bleaching tray eight times, although on the average, most patients will be able to get only 2-3 doses per syringe. One of the reasons is the barrel with the potassium nitrate, where two calibrations out of eight were not even filled in one of our sample syringes. If a patient is using a syringe such as this one, he or she would have to waste 25% of the peroxide just to get to point where it could be mixed with the potassium nitrate. The printing color on the syringes is black. While the kit is prominently marked Nite White Excel 3 Turbo, the syringe itself only is imprinted with Turbo 6% Z (for zero sensitivity). The expiration date is on a label on the bottom of the box. 1 2 3 4 5 LEAST FLOW pH 6.0 Flavors One: mint, that is more neutral than minty. Packaging 2-syringe kit has a contemporary black cardboard, rear-attached lid that opens to reveal a charcoal grey plastic tray securing the two syringes of material, syringe tips, and a case for the bleaching trays. There is an opening in the middle of the lid that exposes the syringe case that is placed in a recess in the box. The tray case is a sleek, expensive-looking, translucent charcoal grey retainer-like box with an unusual surface finish and Discus Dental embossed on the bottom. The two syringes are secured in a separate translucent grey plastic case. The Discus symbol is placed in the center on top of each plastic case. There are grooves inside each of the plastic cases that secure two or three syringes and 2 or 3 tips. The inside of the box lid contains some general instructions for the patient. The syringes are all the dual-barrel design and have been imprinted with eight calibrations, guiding the patient to dispense the correct amount of bleaching gel into the bleaching tray, with ©2005 REALITY Publishing Co. Vol. 19 Reservoir Material Not recommended. Directions Dentist None in the kit, but there is a double-sided postcard with four color illustrations on how to fabricate a bleaching tray in the bag holding the tray material. Straightforward and easy to understand. However, it is suggested to use Splash Lite Body for the bleaching tray impression, even though this low viscosity material has excessive flow for placement in an impression tray and is not as effective as a higher viscosity material. Patient Small glossy booklet with two photos, placed under the syringe case. Gives good advice on handling sensitivity. Marketing Materials Nothing specific for this product. Multitude of materials for bleaching in general and other products. Auxiliary Materials Speed Stone. This is a fast-set stone, which can be used for same appointment models. Even though you can separate the model from the impression after the package-indicated time of five minutes, our models were still not rock-hard. We suggest waiting 10 minutes just to be on the safe side. Speed Spray surfactant is used to reduce bubbles when pouring models. It worked well. Speed Release is a silicone spray used for model lubricant. Doublecurved scissors to trim trays are particularly effective and make scalloping a cinch. The Ratings 73 Bleaching Materials Zoom! Take-Home 2c Discus (4.3) www.discusdental.com Cost: $222.00/6 kits ($5.36/ml) 3 • • • • Syringe Weekender Kit Includes: 3 dual-barrel syringes of gel (2.4g/2.3ml ea) Bleaching tray case 3 automix syringe tips Total bleaching material = 6.9ml Cost: $81.00 ($5.87/ml) Touch-Up Kit Includes: • 1 dual-barrel syringe • 1 automixing tip Shelf life: 1 year If you want thick, this is it Could this be the first sensitivity-free bleach? Difficult to remove from embrasures White color does not permit discrete bleaching Composition Hydrogen peroxide. Available with potassium nitrate (Z formula) and without it (regular formula). Concentrations 4% and 6%. Color White. Consistency and Handling 5.0 Very thick. Very easy and precise dispensing into tray. Adheres exceedingly well to teeth. When a tray is removed, half of the bleach remains on the teeth. And, if your patients have open gingival embrasures, this material will not rinse off even with aggressive rinsing—they must use a toothbrush and/or floss. In addition, mixed material was not always homogeneous. 0 1 2 3 4 MOST FLOW 5 LEAST FLOW Packaging Weekender kits have a clean, clamshell-like design, with hard, clear plastic lids hinged at the rear and bases in either silver (regular formula) or metallic blue (Z formula) plastic. These plastic cases plus a single syringe in a conventional cardboard box come in a clear plastic box that opens on each end. The syringes are standard dual-barrel design with the silver plungers. The imprinting on the syringes indicates the peroxide concentration and includes the Z designation when appropriate. This imprinting is also colorcoded: blue for 4% and silver for 6%. The silver tray case is a unique half-moon design. There are eight calibrations to guide the patient when dispensing the bleach into the tray, with each calibration supposedly containing enough bleach to fill a tray. We found, however, that most patients with average-sized teeth were only able to get only 2-3 doses per syringe even if they were careful when dispensing. The Touch-Up kits hold one syringe and come in a thin white cardboard box with a side-opening lid. Patient instructions are printed on the back of the cardboard box. The expiration date is on a label on the bottom of the clamshell case or side of the box. Bleaching Tray Material Before fabrication: 1.0mm thick. After vacuum-forming, was 0.4mm thick in the middle of the facial surface of the maxillary left central incisor. It is supplied separately from the kit in proportion to the amount of kits you buy at no additional cost. Reservoir Material Not recommended. pH 6.5-6.6 Flavor One: Mint, but it is very subtle. 74 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Directions Dentist None in the kit, but there is a double-sided postcard with four color illustrations on how to fabricate a bleaching tray in the bag holding the tray material. Straightforward and easy to understand. However, it is suggested to use Splash Lite Body for the bleaching tray impression, even though this low viscosity material has excessive flow for placement in an impression tray and is not as effective as a higher viscosity material. Patient Small glossy foldout with two photos, placed in a slot under the base of the case. Good advice, attractively presented. Marketing Materials Nothing specific for this product. Multitude of materials for bleaching in general and other products. Nupro White Gold Dentsply Professional (3.7) 3 Intro Kit Cost: $52.50 ($2.92/ml) Includes: Patient Take Home Portion • 6 syringes with break-off dispensing tips attached (3ml ea) • 1 tray case • 1 patient shade guide Lab Material for Tray Fabrication • 2 sheets of tray material • 1 syringe of Triad Gel VLC Block Out Resin (1.5g) Touch-Up Kit Cost: $11.75 ($1.96/ml) Includes: • 2 syringes with break-off dispensing tips attached (3ml ea) Shelf life: 2 years Composition Carbamide peroxide. 15% contains fluoride. Concentrations 10% & 15%. Color Clear. Consistency and Handling 5.0 Very thick, sticky viscosity, easy to dispense. 0 MOST FLOW 1 2 3 4 5 LEAST FLOW pH 5.7-6.1 Flavors One: mint, but more neutral than minty. ©2005 REALITY Publishing Co. Vol. 19 Least expensive Attractive packaging Nothing stronger than 15% Not much marketing support Packaging The kit comes in a silver and blue cardboard box, with two panels in the front that overlap and Velcro together. Inside, the syringes are in plastic carrying cases with recesses to secure the syringes in place. A cardboard insert holds the dark blue round tray case in place. The case has turquoise blue sparkles intermingled with the darker blue, and has the Nupro White Gold emblem in silver on top of the case. To complement the tray case, the 10% syringe plungers and caps are the same dark blue color while the 15% with fluoride syringes have turquoise blue as the accent. The direct imprinting on the syringes prominently indicates the concentration of the gel as well as the product name. The expiration date is on the individual syringes as well as on a sticker on the side of the box. The lab materials come in a thin silver and blue cardboard box that is shrink-wrapped with the intro kit. The block-out resin is kept in place by a square cardboard insert attached to the inside of the box. The tray sheets and instructions are loosely packed inside, next to the cardboard insert holding the block-out resin. Bleaching Tray Material Brand name: none. Before fabrication: 0.9mm thick. After vacuum-forming, was 0.4mm thick in the middle of the facial surface of the maxillary left central incisor. It shrinks when heated in a vacuum-forming machine. Reservoir Material Triad Gel VLC Block Out Resin. Somewhat thick — needs to be aggressively manipulated to cover the facial surfaces of the teeth in a relatively thin layer. The Ratings 75 Bleaching Materials Directions Dentist Glossy paper booklet with no photos. Relatively brief, but more than adequate for anyone other than a novice. Patient instructions are on the last page of the booklet. Patient Printed on a glossy small foldout enclosed with the twopack syringe set. On one side, there are six color photos. Advises that you should follow “your dentist’s instructions”, and then states each syringe contains approximately three-to-five treatments. They do make the recommendation of wearing the trays for 4a NEW a minimum of two hours. Also has a small note to refrigerate the gel when not in use for more than two weeks. The patient instruction foldout is also inside the cover of the two-syringe travel kit. Marketing Materials Brochures, postcards, statement stuffers. Fairly middle-of-theroad. Won’t dazzle anyone, but also won’t offend. Poladay SDI (3.6) www.sdi.com.au SAMPLING Cost: $29.10 ($2.24/ml) 10 Syringe Kit Includes: • 10 syringes of gel (1.3g/1.3ml ea) • 2 sheets of tray material • 10 tips • 1 tray case • Shade Guide Card • Total bleaching material = 13.0ml Refills: Cost: $99.00 ($1.52/ml) Includes: • 50 syringes • 50 tips • Total bleaching material = 65ml Shelf life: 2 years at room temperature, 3 years refrigerated Concentrations 3%, 7.5%, and 9.5%. Excellent selection of concentrations Least expensive Lackluster packaging Mediocre directions Composition Hydrogen peroxide. Also includes fluoride, proprietary desensitizing agent, and Chitosan, which is a polysaccharide found in the exoskeleton of shrimp and crabs and is chemically similar to cellulose. If your patient is allergic to shellfish, you may want to dispense another product. It presumably acts as a natural soother and conditioner that inhibits plaque formation and aids in calcium absorption to further reduce sensitivity and ion loss from enamel. Color Clear. Consistency and Handling 5.0 Very thick, sticky viscosity, helps to keep gel in contact with the teeth. 0 1 MOST FLOW 2 3 4 5 LEAST FLOW pH 6.0-6.4 Flavors One: spearmint. 76 The Ratings ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Packaging The kit is a conventional cardboard box with a removable white plastic tray securing the contents. There is no other identification on the box among the peroxide versions other than a label on the top of the lid. The top five syringes of bleach are secured in a removable translucent plastic tray, while the other five syringes reside in cutouts in the main white tray. The tray case is white plastic with a conventional shape and SDI embossed on the top. The tips for the syringes need to be attached. The direct imprinting on the syringes indicates the concentration of the gel. These syringes are clear plastic and contain enough material to fill the bleaching tray twice if you are bleaching the entire arch (first molar to first molar). There are no calibrations on the syringe for dispensing guidance. The expiration date is on a label on the side of the lid and is also imprinted onto the syringe itself. Bleaching Tray Material Before fabrication: 1.0mm thick. After vacuum-forming, was 0.4mm thick in the middle of the facial surface of the maxillary left central incisor, but it “feels” much thinner, even flimsy. While it has slightly larger dimensions compared to the other tray materials, this sheet literally melts in the vacuum-forming machine before it can be brought down over the model. There is a real steep learning curve when making a tray with this material. You also have to wait until the material completely cools off to remove it from the vacuum-forming machine because it becomes very sticky. In addition, the material that comes with the kit is smooth on both sides, while the material in refill bags has one smooth and one textured side. Reservoir Material Brand name: Spacer Resin. Very light blue, somewhat thick—do not apply evenly without extra manipulation. Directions Dentist Plain paper foldout in eight languages. More appropriate for patients than dentist. Somewhat outdated, since it does not mention the 9.5% version. Composition listed also doesn’t correlate with marketing materials, since there is no mention of a desensitizer or Chitosan. No photos. Patient Plastic-laminated card with five color illustrations but no words whatsoever. Marketing Materials Postcards, brochures, and patient assessment worksheet, which is basically an esthetic screening form. The brochure features a pretty young woman on the cover and covers all versions of the Pola line of bleaches in a Q&A format. treswhite Ultradent (3.6) www.ultradent.com 4b NEW Patient Kit Cost: $39.99 ($4.00/pack or $2.00/tray) Includes: • 10 packs (two trays/pack) Shelf Life: 1 year refrigerated Better coverage than White Strips Keeps bleaching in the dental office, where it really belongs Trays not as comfortable as strips or paint-on products No single arch packaging Composition Hydrogen peroxide. Color Clear. Concentration 9%. ©2005 REALITY Publishing Co. Vol. 19 The Ratings 77 Bleaching Materials Consistency and Handling 5.0 Very thick, very sticky viscosity, keeps gel in contact with the teeth but also makes it difficult to rinse off. 0 1 2 3 4 MOST FLOW 5 LEAST FLOW pH 6.6 Flavors Two: mint and melon. Packaging The kit is a vertical translucent plastic box with a removable, pulloff cardboard top. Inside are 10 plastic trays with foil-lined, paper lids. Both the trays and lids are disposable. Inside you will find a thin plastic membrane-like tray that is stabilized and carried to the mouth in a stiff plastic secondary tray that is immediately discarded after the thin tray is secured over the teeth. Color-coding according to the flavor is found on the kit’s top, on paper lid of the plastic trays, and on the stiff secondary tray. Green is mint and peach is melon. However, if you are not familiar with the colorcoding, there is a sticker on the side of each kit with the flavor. This box has a contemporary look, but the sharp corners of the plastic are uncomfortable during opening. The expiration date is on a label on the bottom of the main box. Bleaching Tray Material Prefabricated. Reservoir Material N/A. Use Once the membrane-like tray is in place, the patient needs to distribute the gel evenly over the facial surfaces of the teeth by adapting or pressing on the outside of the tray with his or her fingers. This moves the gel cervically from its incisal resting position. There is also a secondary gel at the gingival crest position that presumably prevents any overflow of bleach onto the tissue, where it could cause irritation. However, some early adopters have complained about tissue irritation despite the presence of the gel meant to prevent it. This irritation can probably be minimized by not extending the wearing time beyond the aforementioned recommendations. Directions Dentist None. Patient Foldout card with six color photos. Advises bleaching for 30-60 minutes per day. Marketing Materials Large cardboard cards and posters featuring a variety of models that project a very natural appearance. REALITY Opalescence, the original thick bleach, has the best, most convenient, single use syringes, and slick packaging. With the demise of the “F” version, you now only have to choose between regular and PF. We suggest PF, although don’t expect a total absence of sensitivity. Day White Excel 3, with its easy dispensing and reasonably pleasant taste, is the strongest hydrogen peroxide-based product in this category. Its 9.5% concentration translates into the equivalent of 28.5% carbamide, which is virtually the same as the 30% carbamide products. For patients who can only tolerate short bleaching sessions, this would be a good choice. Zoom! Take-Home and Nite White Excel 3 Turbo are identical products, except that the former also comes in a 4% version, while both products come in 6% hydrogen peroxide. Both products piggy-back off strong brethren and can leverage off their brand equity. Bleaching efficacy with these products is presumably faster than other home bleaches due to “revolutionary surfactant technology helps to improve gel penetration.” In addition, the activation matrix supposedly 78 The Ratings helps “regulate the release of free radicals” over an eight hour period. These types of claims are difficult to validate, but most evaluators reported excellent results, with only one finding only slight whitening. Nevertheless, with all evaluators reporting virtually no sensitivity, this product appears to be a good choice for patients who have bleached before but quit due to hypersensitive teeth. The gel itself is quite thick, which permits precise dispensing into the tray and keeps it in intimate contact with the teeth. If your patient has ever used a runnier bleach and still fears about getting a sore throat, this is the product to use — it will definitely not run down anyone’s throat. But it is pure white, not clear. Since you are supposed to wear the tray for 4-6 hours, this is certainly not the product to use if you don’t want people around you to know you are bleaching. Excess gel is reasonably easy to remove from the soft tissue with a wet finger, but this material is very adherent and somewhat difficult to extricate from gingival embrasures, especially if the papillae are recessed. It is available in one neutral flavor — not particularly offensive, but not overly pleasant either. ©2005 REALITY Publishing Co. Vol. 19 Bleaching Materials Note: In one syringe of the Turbo version, the white barrel was not completely filled at the tip of the syringe—it was short two calibrations. If you find syringes such as these, you should return them to Discus for full syringes. In another syringe of Turbo, the bleach literally dissolved and was largely washed out of the tray after about two hours of bleaching. This is also not typical and should be returned to Discus for new kits. Nupro White Gold has attractive packaging and the lowest price, but its top strength is just 15%, it only has one flavor, and its marketing materials are not in the same league as the other products. Poladay has an excellent selection of concentrations and the lowest price, but it only has one flavor, and its packaging and marketing materials are not in the same league as the other products. Its tray material tends to “melt” when heated—you would be better using Sof-Tray. In addition, sensitivity still occurred with the 9.5%--best to use the lower concentrations for patients who have had sensitivity to bleaching in the past. treswhite is obviously targeted at the White Strips/OTC market. This along the lines of “If you can’t beat them, join them” philosophy. And it does its job in this regard reasonably well, at least as good as the OTC competition and probably better. Just don’t expect the comfort, control, and efficacy of a professionally made, custom tray system. Many people are willing to forsake those refinements for price and convenience. Patients liked the packaging and flavors and, due to the basic design of the membrane-like trays, there is coverage back to the first molars unless the patient has a very large arch. This leapfrogs White Strips, which only cover canine to canine. However, the trays do not adapt very well to the teeth, especially if they are malpositioned, and are not as comfortable or invisible as strips or paint-on products. In addition, this gel takes stickiness to a whole other level. Even very vigorous rinsing has a problem dislodging it from teeth and embrasures. On the other hand, in our clinical evaluation, sensitivity occurred only occasionally along with gingival irritation for most patients, although there were some patients that could not adapt to this system at all. OTHER PRODUCTS IN THIS CATEGORY POWER AcquaBrite AcquaMed ArcBrite Biotrol BriteSmile BriteSmile Excel 3 Power Bleach Discus GentleBright Lumalite Rembrandt Lightning Plus Oral-B Super-Oxal Life-Like Superoxol Sultan Chemist 35% Hydrogen Peroxide Life-Like ASSISTED Karisma C-Dent Life-Like At-Home Life-Like Lustredent 30% Murphy Nite White Excel 3Z-CP Discus Nu Radiance Duet Nu Radiance Gel-White Temrex Oxyfresh ToothWhitening System Oxyfresh 44% Carbamide Peroxide Life-Like Perfecta Premier white & brite 30 OMNII Products Perfecta Bravo Premier HOME Perfecta Ultra Premier Opalescence Endo Ultradent Aspire-Teeth Whitening System Dent Zar Platinum Colgate Oral Pharmaceuticals OpusWhite Laser Whitening System OpusDent At-Home 30% Fast Whitening Life-Like Platinum Overnight Colgate Oral Pharmaceuticals Pola Office SDI Forte Nu Radiance Pola Night SDI High Concentration At-Home Life-Like Rembrandt Smile Oral-B Hi Lite Shofu Illumine Dentsply Professional Laser Smile Biolase LumaWhite Lumalite ©2005 REALITY Publishing Co. Vol. 19 Rembrandt Whitening Strips Oral-B Star*White Temrex Stark White Tru-Tain StayBright Take-Home Whitening Enhancer Lumalite Vari-Shade Lochemco VivaStyle Ivoclar Vivadent White & Brite Omnii Whitestrips Proctor & Gamble Xantia Dexcel Pharma Zaris 3M ESPE The Ratings 79 Everything summed up on one sheet of paper. (You can thank us later.) Bleaching Consent Pads Your patients will be well-informed and your practice protected against potential lawsuits. No other consent form explains bleaching in this detail. To order call 800.544.4999 or 281.558.9101 or order online at www.realityesthetics.com or look for the order form in this edition.