First Whitener for Fixed Braces Orthodontics

The use of the hydrogen peroxide as a dental whitening agent was first described by Kingsbury in 1861.

The dentists' desire to provide fast and effective teeth whitening procedures was described by Abbot in 1918, when he introduced a wonderful and revolutionary in-office dental whitening, a 35% hydrogen peroxide concentration together with heat emission from a lamp to increase oxidation (1).

Doctors Haywood and Heymann described a technique for daily use in 1989 that used a low Carbamide Peroxide concentration to remove deeper teeth stains, which increase with patient’s age (2).

Dental Whitening Popularity
The success of Hydrogen Peroxide-based teeth whitening products have been historically accepted and validated by research.

Messages on TV, newspapers, magazines and other media have popularized dental pigments and teeth stain removal, caused by age, food, beverages with colorants, cigarettes and tea, among others causes. People ask for dental whitening treatments to achieve a better aesthetic, improve their smile and their self-esteem, all of which is closely related to serious dental pigmentation factors (3).

The successful use of H2O2 for dental whitening, using different techniques for in-office and at home treatment, has been described by many authors (4).

Patients under orthodontic treatment are convinced they must maintain their oral health regarding color and aesthetics. Dentists and patients understand that there is the possibility of generating gingival irritations and dental pigmentation alterations caused by bacterial plaque accumulation around orthodontic devices, such as brackets, bands and arches, all this added to the decalcification processes and to the long-term adverse factors, as a poor oral hygiene. Conventional home care includes tooth brushing (mechanical or manual), irrigation devices, fluoride mouth rinses, topical fluoride applications and dental floss usage. But even with all this armamentarium, there is a low motivation (5).

The vast majority of these devices and techniques used for oral health hygene are not implemented by the majority of patients that go at least twice per year to the dental office, and therefore benefits and results are not really significant. We should emphasize other alternatives, that added to the described above and together with patient awareness, could help us improve oral health of patients undergoing orthodontic treatment.

Health and Aesthetics
Oral health and hygiene are important factors to keep in mind in patients who are being treated with orthodontic devices; an excellent hygiene is associated with the need for an appropriate dental aesthetics during and after treatment. Appealing to this desire for optimal aesthetics, we can implement parallel treatments that will maintain optimal periodontal health and at the same time protect teeth by increasing teeth enamel micro-hardness and making them less decay-prone. This is possible thanks to the new dental whitening that contains fluoride and potassium nitrate ions in its formula (5).

For these patients, we have developed a product called Opalescence TresWhite Ortho (Ultradent, Opal Orthodontics, South Jordan, UT) that prevents decalcification due to bacterial attack, which is responsible for carious lesions, and also increases teeth enamel micro-hardness.

TresWhite Ortho is presented with an entrenched external tray which holds another very flexible one for home or in-office use, easily adaptable to teeth and brackets topography. This flexible tray contains an 8% concentration of hydrogen peroxide, fluoride and potassium nitrate dosage. The flexible tray containing hydrogen peroxide should be kept on the brackets for a 45 minute period to achieve adequate contact time between whitening gel, teeth and brackets. After each 45-minute daily session, the soft tray is easily removed from the mouth and discarded, and after that the patient removes gel remnants by brushing.

TresWhite Ortho is the first dental whitening method that works on fixed orthodontic devices and on preventing enamel demineralization. Hydrogen peroxide bacterial and plaque removal, and gingival tissue healing or scarring effectiveness was proved more than 35 years ago (6,7,8,9). Bacteria such as Streptococcus mutants (SM) and Lactobacillus (LB) are responsible for the enamel demineralization white spots. Both types of bacteria are anaerobic, meaning that they need a dark, warm and oxygen-free environment to survive, because their organisms are unable to discard or detoxify in the presence of oxygen radicals (10). Nascent oxygen hydrogen peroxides conversion causes tissue and oral environment oxygenation, and subsequently creates an inadequate environment for bacteria growth and reproduction.

Overcoming Reluctance
Many young and adult patients are reluctant to wear fixed orthodontic brackets because of their unattractive aesthetic appearance. Adequate oral hygiene is more difficult to achieve when wearing these devices, and after months or years of treatment, patients’ teeth usually become dark or pigmented, thus increasing patient rejection to orthodontic treatments.

The use of already medicated, adaptable and malleable trays for home or in-office treatment is an excellent and easy way to provide patients the opportunity to have sparkling white teeth during orthodontic treatment (11).

TresWhite Ortho hydrogen peroxide conversion to oxygen is highly beneficial for eliminating gingivitis due to the ability to provide the extra required oxygen during the high-oxygen consumption by the inflamed gingival tissues (12,13).

TresWhite Ortho whitening power has an additional and predictable benefit. Hydrogen peroxide has a low molecular weight of 32 mg/m, which allows its easy diffusion through enamel to dentin12. Once it spreads to the dentin, oxygen molecules act upon the dark pigments rotating and fragmenting them, creating a whitening effect in the dental structure (14).

Hydrogen peroxide whitens poly-directionally inside the teeth, even underneath places covered by orthodontic devices as brackets, making it possible to obtain homogeneous whitening on patients wearing orthodontic devices12. Patients are very receptive and keen to use this whitening product. Additionally, dental whitening increases the responsibility for maintaining a good oral hygiene.

An 18-year-old patient is more receptive to a treatment based on a dental whitening product than to brushing with fluoride toothpaste or using anti-plaque mouth rinses. This is quite evident when removing the soft TresWhite Ortho tray, since teeth must be vigorously brushed to remove the viscous hydrogen peroxide based whitening gel remnants. The result is chemical and mechanical removal of filaments and bacteria from the teeth surface and brackets.

As oral health professionals we desperately work to increase patient’s awareness for functional, healthy and aesthetic orthodontic treatments.

TresWhite Ortho is effective in removing bacteria and achieving enamel hardness, leaving patients white bright and sparkling teeth. But more importantly, it leaves teeth healthy and fissure-free. This type of result must be our new maintenance and care methodology for modern orthodontic therapies.

Authors
*Dr. Enrique Jadad, DDS, is an specialist in Oral Rehabilitation, and Associate Professor at Cartagena and Santiago de Cali Universities in Colombia. He is also an international visiting professor at Viña del Mar University, Chile. Contact him at: ejadad@gmail.com.

**Dr. Jaime Montoya, DDS, is an Orthodontic specialist is in private practice in Barranquilla, Colombia. Contact him at: jamontoya72@gmail.com.

*** Dr. Arana Gordillo is a Professor at Santiago de Cali University, and a researcher in aesthetics and biomaterials who leads the BEO Research Group. Contact him at: gonzalo.arana@usc.edu.co.

Resources
• www.ultradent.com

References
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