Essential principles of tooth whitening (2024)

Tooth whitening dates back surprisingly far in history. Pearly white teeth have long symbolised beauty and wealth. Ancient Roman dentists believed in using urine with goat milk to make their teeth look whiter. In the late 1920s, mouthwash containing pyrozone (ether peroxide) was found to reduce cavities while providing a whiter appearance to teeth. By the 1940s and 1950s, ether and hydrogen peroxide gels were used to whiten vital teeth, whereas non-vital teeth were whitened using pyrozone and sodium perborate. In the late 1960s, Dr William Klusmeier, an orthodontist from Fort Smith, Arkansas, introduced the first custom tray bleaching. However, it was not until 1989 that Haywood and Heymann published an article in support of this method.

Tooth whitening, once seen as a luxury has now become the norm amongst many treatments offered in general practice. Social media, celebrity influence and the COVID-19 'zoom boom' have all contributed to patients' desire for a whiter, brighter smile. Whitening can offer fairly dramatic results without the need for extensive and/or invasive treatment or cost. It is important that dental practices offering tooth whitening follow the current guidance and legislation. This article looks at the questions we commonly get asked from our members regarding tooth whitening and the practical aspects for dental teams.

Which members of the dental team can carry out tooth whitening?

Only dentists can prescribe tooth whitening, however the first application for each cycle of tooth whitening can be delegated to an appropriately qualified hygienist, therapist or clinical dental technician under the direct supervision of a dentist (that is, with a dentist on the premises).

Thereafter, the patient can complete the tooth whitening cycle at home.

A hygienist cannot carry out tooth whitening under direct access arrangements.

What should I do before providing whitening for a patient?

Before providing tooth whitening, you must carry out an appropriate clinical examination of the patient to ensure there are no risk factors or other oral pathology concerns that would contraindicate whitening. The patient's clinical records should provide a record of your discussions with the patient and demonstrate that you obtained valid consent. Discussions should include information about the costs involved, the potential adverse effects and that the result cannot be accurately predicted. Pre-treatment photographs (ideally with a shade-guide in situ) should form part of the patient's records.

If I am constructing whitening trays in-house, what do I need to do?

Whitening trays do not come within the remit of medical devices because there is no medical purpose for them, just aesthetic. Therefore, practices do not have to register with the MHRA for making them. Team members constructing trays should have had appropriate training and instruction, and this should be documented.

What products am I allowed to use?

Products containing or releasing between 0.1% and 6% hydrogen peroxide can only be sold to dentists and be made available to a patient via treatment provided by a registered dental professional; they should not be made directly available to the patient. These products cannot be used on anyone aged under 18 years unless it is for the treatment or prevention of disease. If you believe that the legislation is preventing you from providing the treatment you believe to be in the best interests of your patient, you should seek advice from your indemnity provider. Regulations prohibit the use of products that contain or release more than 6% hydrogen peroxide unless it is wholly for the treatment or prevention of disease.

What about top ups?

After the initial course of whitening, top up gels should not be provided without a new clinical exam by the dentist. The issue is that the GDC do not define how long a course can be, but the dentist's duty extends to continuing to monitor the provision of top-up gels and ensuring this is in accordance with the patient's treatment plan.

As the cycle duration is individual to each patient, there is no set maximum interval between examinations before issuing top up gels. All this would have to be decided on a case-by-case basis. A 'cycle' can be taken to mean the time taken to achieve the desired results.

If you provide patients with a supply of top-up gels but did not provide the initial course of whitening, you must treat this as a new cycle and undertake a clinical examination before administering the first application yourself or delegating it to an appropriately qualified DCP working to your prescription and under your direct supervision.