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Tray tooth bleaching involves the use of carbamide peroxide in a custom-fitted tray to bleach teeth. One of the most difficult stains to bleach is tetracycline. This paper will present several different patient situations of tetracycline-stained teeth being bleached and will discuss the benefits and limitations of bleaching tetracycline-stained teeth. By providing the patient with realistic potential outcomes of bleaching, as well as the preservation of tooth structure and cost-benefit ratio of bleaching compared to veneers or crowns, the chance for a successful acceptance of the outcome is better, even if the outcome is less than ideal. Bleaching before prosthodontic treatment can also provide a better outcome for subsequent veneers or crowns if that is possible, but sensitivity may preclude bleaching.

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OBJECTIVE: To provide an update on tray bleaching for various tooth discoloration conditions, including a complete examination form as well as an information and consent form. CLINICAL CONSIDERATIONS: Since the bleaching process was first documented in 1989, it has become a safe, successful, and conservative treatment for consistently whitening the color of patients' natural teeth. Though initially used on a limited basis, the process has expanded to include bleaching nicotine and tetracycline stains, single dark teeth, brown spots, reducing white spots, caries control as well as color change from aging. Ten percent carbamide peroxide is the material most used in research and has shown to be the most effective with the least amount of adverse side effects, including sensitivity or gingival irritation. Bleaching overnight using a smooth nonscalloped, nonreservoir vacuum-formed tray has been shown to be the method of choice for most clinicians, leading to greater patient compliance and an overall successful treatment. When possible, conservative bleaching treatment should be considered prior to more invasive, irreversible procedures such as veneers, or crowns to meet patients' esthetic requirements. Because of its basic pH, and potential for caries inhibition, complete restorative treatment does not have to be performed prior to initiating bleaching, making it an extremely flexible treatment. CONCLUSION: With a thorough bleaching analysis, proper treatment of appropriate discolorations over an ideal timeframe, tray bleaching is a powerfully predictable tool in restorative dentistry. CLINICAL SIGNIFICANCE: Tray bleaching with 10% carbamide peroxide should be the first consideration for treatment of discolorations of any type, with varying times of treatment, even in the presence of mild decay.

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Clear aligner treatment has become popular for many orthodontic cases that ordinarily would have required traditional orthodontic brackets and wires. One of the motivating reasons for patients to use clear aligner therapy is to improve their esthetic appearance, which typically is the same motivation for teeth bleaching, thus a combination of the two treatments may be desirable. The case report presented demonstrates bleaching concurrent with clear aligner (Invisalign®) treatment. A concern about bleaching during such treatment is that the areas on the tooth under the composite attachments, or buttons, used to retain the clear aligner trays may remain unbleached. However, due to the small molecular size of the bleaching material agent and its ability to permeate the tooth, the area under the attachment will be bleached as well. With this understanding, a practitioner can treat patients more efficiently by being able to complete bleaching treatment simultaneously with clear aligner treatment.

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Bleaching has changed the way the world looks at teeth, with lighter teeth becoming the norm due to the ease and simplicity of tray bleaching. The resultant lighter teeth have changed prosthodontics in that there is less need for some types of restoration, less aggressive preparation design, as well as new techniques for shade selection, caries control and managing gingival health.

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Traditionally, testing for whether pit-and-fissure caries should be restored involved probing with a sharp explorer and evaluating resistance to withdrawal (ie, "stick"). Alternative visual methods of evaluation and classification have been proposed, validated, and accepted formally in the core curriculum on caries management in both Europe and North America. This article examines the resistance to occlusal breakdown of fluoridehardened enamel despite progression of underlying dentin caries with accompanying difficulty in diagnosis. Traditional methods of pit-and-fissure caries diagnosis, including radiographs or fissure probing with an explorer, have been shown to be inaccurate and potentially destructive. The clinical process of using the visual/tactile International Caries Detection and Assessment System (ICDAS) and/or the Caries Classification System (CCS) is described and illustrated through case examples.

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UNLABELLED: Objective Peripheral enamel staining is often noticed after removal of long-term veneer or crown provisional restorations. Application of carbamide peroxide (CP) easily removes the stain, but the potential for immediate bonding with a resin-based cement is questionable. This project tested the short-term, shear bond strength of a commercial, photo-curable, resin cement to bovine enamel after application of a 10% concentration of CP placed for different exposure times. MATERIALS AND METHODS: Bovine enamel was flattened and polished. Surfaces had either no CP application (control), or 10% CP applied for 10, 20, or 30 seconds. Teeth were acid-etched, rinsed, dried, and controlled sized stubs of a commercial resin cement were photocured onto the treated surfaces. The shear bond strength of each specimen was determined using a universal testing machine, and results were compared using an analysis of variance at a preset alpha of 0.5 (n = 10/group). RESULTS: No significant differences (p = 0.819) in shear bond strength were found among any CP cleaning treatments or the experimental (nontreated) control. CONCLUSIONS: Short-term application of 10% carbamide peroxide prior to acid etching, to remove enamel stains in teeth prepared to receive ceramic veneers or crowns, does not reduce immediate shear bond strength of resin-based cement to enamel. CLINICAL SIGNIFICANCE: Clinicians can confidently apply 10% CP for short-term, localized stain removal on enamel and not be concerned about affecting subsequent bond strength of a resin-based cement to enamel. (J Esthet Restor Dent, 2016).

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When a dental school is deciding which technology to introduce into a curriculum, it is important to identify the educational goals for the system. The authors' primary goal for the use of a computer-aided resource was to offer students another way to assess their performance, to enhance their learning, and to potentially decrease their learning curve in the preclinical environment prior to using the technique in clinical patient care. The aim of this study was to examine the validity of the "% Comparison" numbers derived from the E4D Compare software program. Three practical examinations were administered to a class of 82 students at one U.S. dental school over a six-week period. The grading of the practical examinations was performed with individual faculty members being responsible for evaluating specific aspects of each preparation. A digital image of each student's practical examination tooth was then obtained and compared to the digital image of an ideal preparation. The preparations were compared, and the "% Comparison" was recorded at five tolerance levels. Spearman's correlation coefficient (SCC) was used to measure the agreement in rankings between the faculty scores on practical exams 1-3 and the scores obtained using E4D Compare at the different tolerance levels. The SCC values for practical exams 2 and 3 were all between 0.2 and 0.4; for practical exam 1, the SCC values ranged from 0.47 to 0.56. There was no correlation between the faculty scores and the numbers given by the "% Comparison" of the software.

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STATEMENT OF PROBLEM: Regardless of the type of indirect restoration being fabricated, optimizing fit at cementation is a challenge. Several disclosing agents have been recommended to identify intaglio surface contacts that may result in incomplete seating and poorly adapted margins. The International Organization for Standardization has established a standard of 25 µm for the maximum film thickness for water-based cements. To accurately predict the clinical behavior of a luting cement, the disclosing agents themselves should have a film thickness no greater than 25 µm. PURPOSE: The purpose of this study was to determine the film thickness of 2 disclosing products, a spray-on powder (Occlude Indicator Marking Spray) and a silicone disclosing agent (Fit Checker). MATERIAL AND METHODS: The film thickness of the 2 disclosing products was determined by using optically flat glass cylinders according to the method set forth in International Organization for Standardization Standard 9917 for water-based cements. Because the silicone product is fast setting, the load was applied within 10 seconds of completing the mix. The spray-on product was allowed to dry before applying the load, in accordance with its intended clinical use. The film thickness of both products was determined with a load of 150 N applied for 30 seconds. Additional determinations were made for the silicone product at both 100 N and 50 N applied for 30 seconds and at 150 N applied for 90 seconds. An additional film thickness determination for the spray-on product was made with no load applied. The film thickness data for the various loads and intervals for the silicone product were analyzed with a 1-way ANOVA and the Tukey-Kramer multiple comparison test (α=.05). A t test (unequal variance, 2-tailed) was used to compare the spray-on and silicone products as measured at a load of 150 N applied for 30 seconds. RESULTS: The average film thickness of Fit Checker ranged from 16.7 to 23.7 µm, with the two 150-N groups significantly lower than the others, whereas that of Occlude was 67.7 µm unloaded and 48.4 µm when loaded. The film thickness of Fit Checker was significantly less than that of Occlude for the 150 N, 30-second group. CONCLUSION: Within the limitations of this study design, Fit Checker had a film thickness that satisfied the 25-µm limit imposed on water-based luting cements in the International Organization for Standardization standard, whereas Occlude Spray did not.

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To perform fixed prosthodontic procedures, dentists take a full-arch or quadrant impression and articulate the casts. The dual-arch impression technique is a popular quadrant technique for crown fabrication. The technique described in this article, which uses a quadrant impression and separate interocclusal record, offers several advantages over the traditional dual-arch method.

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BACKGROUND: Plaque accumulation and resulting caries or periodontal disease is a frequent problem in patients with special-care needs. Tray-applied 10 percent carbamide peroxide (CP) is a tooth-bleaching agent that has positive effects on plaque, gingival health and caries. METHODS: The authors review the antibacterial properties of CP and the effects of CP on saliva, plaque, caries and gingival health. They also review tray fabrication options and techniques, application methods, safety and side effects. Finally, they address the challenges involved in and research needed regarding use of tray-applied CP materials in special-care patients. RESULTS: In their literature review and clinical experience, the authors found 10 percent CP delivered in a custom-fitted tray to be an effective treatment for caries in patients with compromised oral hygiene. Plaque suppression and caries control result from a CP-induced increase in salivary and plaque pH caused by CP's urea component, and from possible antimicrobial action via physical debridement and the direct chemical effect of hydrogen peroxide. CONCLUSIONS: Tray-applied 10 percent CP may hold great promise for improving the oral health of many special-care patients, including elderly patients, patients with cancer and patients with dry mouth. Further research is needed to verify the potential benefits, specifics of treatment times and protocols and most cost-effective products for use in various patient groups. CLINICAL IMPLICATIONS: Application of 10 percent CP in a custom-fitted tray may reduce caries by elevating the pH above the level at which the caries process can occur, in addition to debriding the teeth and improving gingival health.

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This article describes a method of in-office fabrication of an occlusal device for treatment of bruxism patients seeking a less costly alternative to laboratory-processed splints. This technique eliminates the need for mounted casts and the expense and delay associated with commercial laboratory involvement. It also minimizes patient and operator exposure to acrylic resin monomer and high temperatures associated with its polymerization reaction by use of a light-polymerized blue urethane dimethacrylate resin.

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We have incorporated an audience response system into our curriculum to increase student interaction in the teaching process. Classroom Performance System (CPS) is a computer-based audience response system that allows students to answer questions posed to the entire class by entering responses on a keypad. The responses are tallied and displayed on the classroom screen for all students to see. The purpose of our study was to determine student accuracy using the system with three different methods of administering questions. A secondary purpose was to assess students' perceptions about using the system. Our hypothesis for the study was that there should be no difference in volunteer accuracy or questionnaire responses to the three methods of gathering responses. Sixty-two dental students volunteered to participate. Using three methods (projected on a screen, verbal, and written), volunteers were given "responses" to enter into the system using CPS wireless remote answering devices. In the projected and verbal formats, the teacher managed the assessment by controlling the pace of input. In the written format, students were given responses on paper to input into the system at their own pace. At the end of the sessions, volunteers completed an anonymous questionnaire regarding their experiences with the system. The accuracy of responses was similar in the teacher-managed assessments (projected and verbal format). There was a statistical difference in the accuracy of responses in the student-managed assessment (p=<0.000001). Questionnaire responses also showed that students preferred teacher-managed assessments. The hypothesis was disproved. The overall response to this audience response system and its methods of gathering information was very positive.

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OBJECTIVE: In-office bleaching has become very popular for patients desiring immediate results. This report discusses the efficacy of in-office bleaching using high-intensity xenon halogen tungsten light on 73 patients in a private practice over 6 months. METHOD AND MATERIALS: Thirty-five percent hydrogen peroxide gel was applied to the tooth surfaces, and then both arches were illuminated with the LumaArch unit light for 8 minutes. The entire procedure was completed 3 times for a total application time of 24 minutes. Thereafter, patients returned every 2 weeks for another 24-minute in-office treatment until the patient was satisfied or did not want additional treatment. After completion of bleaching, patients were classified into groups according to the number of treatments they received. When requested, home bleaching was used as a follow-up treatment. The degree of color change and color relapse were evaluated at baseline and immediately, 2 weeks, and 6 months after bleaching. Also evaluated was the number of patients that requested home bleaching. RESULTS: Of the 73 patients who received 1 to 4 in-office bleaching procedures, 58 were satisfied. Twenty-seven patients requested home bleaching. The average color change per appointment was 2.1 to 3.7 units on a 16-scale Vita Classic shade guide. Color relapse was more noticeable at the 2-week interval than at the 6-month postbleaching evaluation. CONCLUSION: In-office bleaching may be an alternative for patients who do not like home bleaching. In-office treatment may achieve satisfactory results, but often more than 1 visit is necessary to achieve patient satisfaction.

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OBJECTIVE: This research systematically evaluated the use of a clinically proven desensitizing dentifrice prior to a bleaching regimen in a randomized, multi-center, parallel group, open label clinical study following Good Clinical Practice guidelines. METHODOLOGY: Fourteen dental offices in West Palm Beach, Florida participated in the study during April/May 2004. Fourteen days prior to bleaching, impressions and oral soft tissue assessments were performed, and patients were randomized to either a KNO3 plus fluoride dentifrice (Sensodyne Fresh Mint), or a standard fluoride dentifrice (Crest Regular), brushing 2x per day. On Day 14, patients returned to the dental office for their custom tray and the dispensation of a bleaching kit (Day White Excel 3; 9.5% hydrogen peroxide and KNO3). This was used daily according to the manufacturer's instructions for 30 minutes, and normal oral hygiene continued to be performed using the assigned toothbrush and dentifrice, brushing 2x per day. At the end of each bleaching day, patients answered diary questions about the occurrence and intensity of sensitivity. At the conclusion of the 14-day bleaching period (Day 28), patients returned to their dental office for re-examination, returning all products and diaries. Within seven days of completing the study, patients answered a telephone patient satisfaction survey. RESULTS: A total of 202 patients in fourteen (14) dental offices completed all aspects of the study and were used for the analysis. The professionally dispensed bleaching product provided an improvement of approximately 4.4 Vita shades, regardless of whether it was used with the KNO3 plus fluoride (Sensodyne) or a standard fluoride (Crest) dentifrice. The patient perception of increased sensitivity caused by the bleaching treatment was low but measurable. In the first week of the bleaching, significantly more patients using the KNO3 plus fluoride dentifrice were free from sensitivity (58%) than the standard fluoride dentifrice group (42%). During the 14-day bleaching treatment period, the KNO3 dentifrice patients experienced significantly more "sensitivity free days" (average = 10.1) compared to the standard fluoride dentifrice group (average = 8.6). CONCLUSION: The use of the KNO3 plus fluoride dentifrice (Sensodyne), two weeks prior to and throughout bleaching, may be a useful adjunct for the management of sensitivity caused by professionally dispensed bleaching products. With the bleaching-induced tooth sensitivity, those patients in the KNO3 plus fluoride toothpaste group were significantly more satisfied with their whitening experience and willing to repeat the bleaching treatment.

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The most common side effect of tooth whitening is tooth sensitivity. There are a number of materials and techniques for reducing sensitivity. This article focuses on potassium nitrate applied either by brushing before initiating whitening or by application via a tray during whitening to reduce sensitivity. A detailed step-by-step procedure for managing hypersensitive patients is described.

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Nightguard vital bleaching, or at-home bleaching using a 10% carbamide peroxide material in a custom-fitted tray, has become the standard for tooth whitening. This article answers many of the questions associated with this process, and compares the procedure with other whitening options.

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