Indications for Bleaching

While many patients might be curious about whitening their teeth, dental professionals need to understand who the ideal candidates for whitening are and when/how to include bleaching in a treatment plan. A full oral examination that includes checking the medical history and noting potential allergies, asking if there is a history of tooth sensitivity, finding out the possible etiology of stain, and checking for any signs of potential infections or oral disease are necessary to start the process.3

An ideal candidate for whitening will be a healthy individual with a complete permanent dentition, preferably someone at least 18 years of age. The individual also must have the desire to be compliant and follow directions, as well as the capacity to understand potential side effects and how to manage them. It is best to avoid the contraindications listed in Table 2.

Table 2. Contraindications for Teeth Bleaching.
Contraindications Reasons
Allergies Ensure patients are not allergic to any of the ingredients in the bleaching material. If they might be, other options may be necessary for them to improve their esthetics. There are no documented reports of allergic sensitivity to HP or CP.9
Tooth Sensitivity Bleaching can cause transient sensitivity in patients, which usually disappears when treatment is stopped.1,8 Learning about an individual’s current sensitivity or that experienced in the past will help manage patient expectations and allow for potential pretreatment to prevent issues during the bleaching process.
Pregnant Pregnant patients are generally not included in research studies such as those testing bleaching agents. Thus, research is unavailable on this population. Consequently, there is no evidence stating it is either safe or not safe to bleach teeth during pregnancy. Therefore, it is always better to avoid bleaching until after the baby is born so as not to take any risks.3,8
Anterior Restorations Restorations will not lighten from a bleaching agent. If anterior restorations are needed, or if patient has anterior restorations, it is important to manage expectations by educating patients that only the surrounding tooth structure, not the restoration, will lighten. Patients should bleach their teeth before having new or replacing anterior restorations, so the shade can be matched at the time they have the restoration placed.
Children and Adolescents It is discouraged to bleach teeth until after all permanent teeth have fully erupted (at least after age 18).3,10 Primary teeth have thinner enamel and larger pulp chambers that are closer to the outer surface than permanent teeth.11 Due to these features, a primary tooth may be more susceptible to adverse reactions and a child may not have the capacity to completely understand risks and what the procedure entails. Primary teeth also tend to have a bluish/white hue where permanent teeth may appear more grey/yellow.11 A difference in shade may be more obvious when a child has a mixed dentition. Evidence-based guidelines for this population are not established and require more research.3,10
Periodontal Disease It is necessary to address periodontal disease and focus on the importance of health before treatment planning a cosmetic procedure such as bleaching. If patients really want whiter teeth, then use this as a motivator to encourage them to take the necessary steps to return their gums to a state of health. Education on the importance of proper homecare, diet, and the connection of periodontal disease and potential staining also may motivate the patient to continue with maintenance to stay healthy and stain free.3
Caries/Failing Restorations A leaky restoration or active decay can cause teeth to be stained. Bleaching will not remove or fix decay.3 Always establish health by treatment planning any necessary work prior to addressing cosmetic issues. The exception is if the decay/restoration is on an anterior tooth, because bleaching may be appropriate to do prior to placing a final restoration since restorations will not lighten after the fact.3,8
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