Balancing the risks and benefits associated with cosmetic dentistry - a joint statement by UK specialist dental societies

Inflammatory parameters and color alterations of dental bleaching in patients wearing fixed orthodontic appliance: a randomized clinical trial

BACKGROUND

Many orthodontic patients request dental bleaching during orthodontic treatment to achieve a faster aesthetic resolution, however, no attention has been paid to the inflammatory processes that can occur when both therapies are indicated together. So, this clinical trial evaluated the inflammatory parameters and color alterations associated with dental bleaching in patients wearing a fixed orthodontic appliance.

METHODS

Thirty individuals aged between 18 and 40 years were equally and randomly allocated into three groups: FOA (fixed orthodontic appliance), BLE (dental bleaching), and FOA + BLE (fixed orthodontic appliance + dental bleaching). The orthodontic appliances and the bleaching procedures were performed in the maxillary premolars and molars. For dental bleaching a 35% hydrogen peroxide was used. The gingival crevicular fluid (GCF) and nitric oxide (NO-) levels were evaluated at different time-points. Color evaluation was performed using an Easyshade spectrophotometer at baseline (FOA, FOA + BLE, BLE), one month after (FOA + BLE) and 21 days after appliance removing (FOA + BLE and FOA groups), in each tooth bleached. The ANOVA and Tukey's tests, with a significance level of 5%, were used for statistical analysis.

RESULTS

The GCF volume in the FOA + BLE and FOA groups significantly increased at the time points evaluated (p < 0.001); however, this did not occur in the BLE group (p > 0.05). On the other hand, NO- levels significantly decreased during dental bleaching with or without fixed orthodontic appliances (FOA + BLE and BLE groups; p < 0.05), while no significant changes were observed in the FOA group (p > 0.05). Significant changes in color were observed in the FOA + BLE and BLE groups compared to in the FOA group (p < 0.01). However, the presence of fixed orthodontic appliance (FOA + BLE) negatively affected the bleaching efficacy compared to BLE group (p < 0.01).

CONCLUSIONS

Dental bleaching did not increase the inflammatory parameters in patients wearing fixed orthodontic appliance. However, in the presence of orthodontic appliances, the bleaching efficacy was lower than that of bleaching teeth without orthodontic appliances.

TRIAL REGISTRATION

RBR-3sqsh8 (first trial registration: 09/07/2018).

Ethical and Medico-Legal Considerations with Aesthetic Dentistry Involving the Aesthetic Zone

The bedrock of delivering cosmetic dentistry remains good communication underpinned by a clear and transparent consent process. This article looks at this while exploring the ethical and risk management issues that have started to challenge the profession. While patients' demand for cosmetic dentistry has exploded, this article explores the ethical conundrums faced by these treatments against the backdrop of whether their happiness is affected by their image.

Present status and future directions - Managing discoloured teeth

Managing tooth discolouration involves a range of different protocols for clinicians and patients in order to achieve an aesthetic result. There is an increasing public awareness in the appearance of their teeth and management of tooth discolouration may be inter-disciplinary and involve both vital and nonvital teeth. Vital teeth can be easily treated with low concentration hydrogen peroxide products safely and effectively using an external approach and trays. For endodontically treated teeth, the walking bleach technique with hydrogen releasing peroxide products is popular. However, there is an association with external cervical root resorption with higher concentrations of hydrogen peroxide of 30%-35%. There are also regulatory considerations for the use of hydrogen peroxide in certain jurisdictions internationally. Prosthodontic treatments are more invasive and involve loss of tooth structure as well as a life cycle of further treatment in the future. This narrative review is based on searches on PubMed and the Cochrane library. Bleaching endodontically treated teeth can be considered a safe and effective protocol in the management of discoloured teeth. However, the association between bleaching and resorption remains unclear although there is likely to be a relation to prior trauma. It is prudent to avoid thermocatalytic approaches and to use a base/sealer to cover the root filling. An awareness expectations of patients and multidisciplinary treatment considerations is important in achieving the aesthetic result for the patient. It is likely that there will be an increasing demand for aesthetic whitening treatments. Bleaching of teeth has also become increasingly regulated although there are international differences in the use and concentration of bleaching agents.

The paediatric dentistry-restorative dentistry interface

This paper examines the various contemporary clinical interfaces between paediatric dentistry and restorative dentistry for patients with both acquired and congenital abnormalities presenting to primary and secondary care. Dental trauma of the child or adolescent has long-standing implications on future oral health due to conditions such as ankylosis, pulp necrosis, coronal tissue loss or tooth loss, all of which provide significant challenges into adulthood. Similarly, congenital conditions, such as hypodontia and structural deficiencies or malformations, such as amelogenesis and dentinogenesis imperfecta, result in the need for collaborative, multi-speciality decision-making from a young age, creating a pathway for longitudinal multi-disciplinary team treatment planning.

Professionalism in the dental practice: perspectives from members of the public, dentists and dental care professionals

Introduction This paper examines views on professionalism in the dental practice workplace through a thematic analysis of data from eight focus groups.

Methods Focus groups were conducted with 19 dentists, 13 dental care professionals and 19 members of the public in England and Wales. The research was part of a larger mixed-methods study of professionalism in dentistry commissioned by the General Dental Council.

Results The four most prominent themes in the focus group data were: communication, the cost of treatment, the role of the dental team and consequences of professionalism concerns. Participants agreed that these are fundamental professionalism issues, although there was some difference of opinion about addressing them. There was disagreement about the responsibilities of different members of the dental team in maintaining professionalism.

Conclusion We conclude that communication skills training should be a central part of the professionalism at all levels of training. Education about team working could foster a more collaborative approach to professionalism across the dental team and support good, patient-centred oral healthcare. Support and guidance are required to help professionals reflect and learn from mistakes.

Highlights the importance of communication skills as a core element of professionalism education.

Suggests that education about team working could foster a more collaborative approach to maintaining professionalism within the dental practice.

Recognises that lapses in professionalism can occur and should be reflected upon as part of ongoing learning.

Effectiveness and Adverse Effects of Over-the-Counter Whitening Products on Dental Tissues

The role of bleaching agents (e.g., hydrogen peroxide) in tooth bleaching is quite well-described in a few literature studies and considered as the option choice for those desiring brighter teeth, but alternative methods have emerged to fulfill the desire of patients in a faster, easier, and cheaper way. In this context, whitening over-the-counter (OTC) products are available in several vehicles, such as toothpaste, rinses, gums, paint-on varnishes, and strips, but their effectiveness in terms of bleaching is questioned. This review aimed to describe their mode of action, whitening effectiveness, and harmful effects associated with the indiscriminate use of these products. Dentifrices usually present a combination of abrasives that can induce damage to the tooth surface without evidence of promoting real bleaching. The same was found for rinses, which might present a low pH, with an erosive potential. Charcoal has been included in the composition of these products to improve their whitening effect but there is no evidence supporting it. Regarding strips, they present hydrogen peroxide in a variety of concentrations and are the only OTC products able to promote bleaching. Despite the vehicle, an indication for the use of these products should be made after a careful individual diagnosis of the etiology of the dental staining, considering that most of them seem to be effective only in removing extrinsic stains or preventing their formation over enamel. Also, their indiscriminate use might induce damage and deleterious effects over tooth tissues or gingival tissues. The dentist should be aware of the composition and mode of action of each individual product as they change according to the composition and the vehicle used to recommend the best mode of usage. Still, there is no sound evidence that any of the described OTC products promote a better bleaching effect than the products indicated for a professional.

The use of social media for professional purposes among dentists in Saudi Arabia

Aim

To investigate the dentists’ opinions towards social media (SM) use in daily practice and the expected limitations from its use in Saudi Arabia.

Methods

An electronic survey was carried out throughout May–June 2020 among a sample of dentists in Saudi Arabia. The survey covered three parts: the first part covered professional and demographic information, the second part covered the use of mobile phones and SM in dental practice, while the third part assessed dentists’ opinion on SM use. Descriptive statistics included frequency distributions and percentages and independent t test/ANOVA test for the relationship between the mean of dentists’ opinion towards SM and demographic variables. A p value of 0.05 or less was considered statistically significant.

Results

The majority of respondents (80%) believe that SM plays an active role in patients’ decisions regarding the selection of a healthcare provider. The mean dentists’ opinion scores on the use of SM were significantly lower among participants working more than 50 h per week compared with other participants (p = 0.014).

Conclusion

The majority of sampled dentists believe that SM plays an active role in patients’ decisions regarding the healthcare provider’s selection. Directed campaigns can help dentists optimize the use of SM for both professional and personal purposes.

The association of external cervical resorption with modern internal bleaching protocols: what is the current evidence?

Internal bleaching is an effective and minimally invasive way of bleaching non-vital teeth. A commonly cited risk associated with it is external cervical resorption (ECR), which is a potentially significant complication that could result in loss of the tooth. This is an important point of discussion with a patient during the consent process. Legally, patients are required to be made aware of material risks to which they would be likely to attach significance, such as the loss of a tooth. The risk of ECR is therefore a key component in the patient's decision-making process as they weigh it against the perceived benefits. Over the last ten years, both clinical and legal reasons have resulted in a number of changes in the materials and protocols used for internal bleaching. This leads to the question of what the current quality of evidence is regarding the association of ECR following internal bleaching with modern protocols. Other restorative options for discoloured teeth, such as veneers or crowns, involve the irreversible removal of tooth tissue and these may be chosen by patients over internal bleaching based on out-of-date evidence.

Wish-fulfilling medicine and wish-fulfilling dentistry

OBJECTIVES

to explain the practice of wish-fulfilling medicine and how it relates to dentistry.

SOURCES

Relevant papers, and reports from authoritative institutions were identified in Pubmed and Google Scholar.

RESULTS

Wish-fulfilling medicine refers to services provided by professionals using medical methods in a medical setting to address non-medical wishes of patients. Care-providers, medical industries, and health-insurance companies also contribute to wish-fulfilling in medicine and dentistry. Various concepts of health and illness compounded by blurred borders between health and illness offer an unstable foundation for wish-fulfilling medicine, and growing demands for these services where healthcare resources are limited can displace medically necessary treatments. Moreover, treatments without a medical or a dental necessity, can be harmful and bear the risk of futile or excessive treatments not in patients' long-term interest. Examples in dentistry are found in the field of cosmetic interventions, prosthodontics and orthodontics, where perceptions of small 'deviations' from normality prompt wishes or recommendations for intervention. Ethically, wish-fulfilling services confront the principles of the common morality if the autonomy of a patient is compromised, beneficence is unclear, harm is foreseeable, or distributive justice is compromised. Wish-fulfilling dental treatment can be restricted by legislation if it conflicts with safe, effective and efficient care, or if it interferes with patient's real needs or undermines established professional standards.

CONCLUSIONS

The general understanding of wish-fulfilling medicine including its ethical and legal themes is relevant to dentistry.

CLINICAL RELEVANCE

Ethical considerations and legislation can guide a dentist to reflect critically on clinical decisions regarding wish-fulfilling dentistry.

A review of the law of consent in dentistry

The development of the law of consent has led to much discussion within the dental literature as to how these changes might impact practice. The move from a practitioner-focused standard of consent to a patient-focused standard has altered the nature of the framework required to support a patient's decision-making to avoid an allegation or finding of a negligent consent process. Contrastingly, there has been little in the way of exploration as to how the law of battery (in civil matters) and assault (in criminal cases), where consent is entirely absent, might apply to dentistry and the practice of the profession. This article considers the law of consent, using several key examples from dentistry, as well as providing an update of recent case law of relevance to dental practice.

Hydrogen peroxide-based products alter inflammatory and tissue damage-related proteins in the gingival crevicular fluid of healthy volunteers: a randomized trial

Hydrogen peroxide (H₂O₂)-based products are effective in tooth whitening; however, their safety is controversial as they may harm patient tissues/cells. These effects are suggested to be concentration-dependent; nonetheless, to date, there are no reports on H₂O₂-mediated oxidative damage in the gingival tissue, and neither whether this can be detected in gingival crevicular fluid (GCF) samples. We hypothesize that H₂O₂ whitening products may cause collateral oxidative tissue damage following in office application. Therefore, H₂O₂ and nitric oxide (NO) levels were investigated in GCF samples obtained from patients undergoing dental bleaching with H₂O₂ at different concentrations, in a randomized, double-blind, split-mouth clinical trial. A proteomic analysis of these samples was also performed. H₂O₂-based whitening products promoted inflammation which was detected in GCF samples and lasted for longer following 35% H₂O₂ bleaching. This included time-dependent changes in NO levels and in the abundance of proteins associated with NO synthesis, oxidative stress, neutrophil regulation, nucleic acid damage, cell survival and/or tissue regeneration. Overall, H₂O₂-based products used in office promote inflammation irrespective of their concentration. As the inflammation caused by 35% H₂O₂ is longer_, patients may benefit better from using lower concentrations of this bleaching product, as they may result in less tissue damage.

Effect of CPP-ACP on efficacy and postoperative sensitivity associated with at-home vital tooth bleaching using 20% carbamide peroxide

OBJECTIVES

To evaluate CPP-ACP effect on colour change and tooth sensitivity (TS) associated with at-home vital tooth bleaching using 20% carbamide peroxide (CP).

METHODS

A randomised double-blind placebo-controlled clinical trial was conducted to measure the TS and tooth colour change of 24 patients at 3-day, 7-day, 14-day and 30-day periods. The participants were instructed to apply 20% CP (7 days-04 h each) followed by the application of either CPP-ACP or non-active placebo paste, delivered by the bleaching custom tray (7 days-30 min each). Lightness (L*), redness (a*) and yellowness (b*) were measured using a digital spectrophotometer and the overall colour changes ∆E were calculated. ∆E and TS values were statistically analysed. The level of statistical significance was established at p = 0.05.

RESULTS

No significant differences were detected between CPP-ACP and placebo groups regarding the ∆E. The ∆E measurements presented significant differences within CPP-ACP groups between 3-day vs. 14-day and 30-day measurements. The CPP-ACP application reduced significantly the TS reported by the participants at 3-day when compared with the placebo group.

CONCLUSION

The application of CPP-ACP paste during at-home tooth bleaching with 20% CP was beneficial since its use reduced the TS and presented no deteriorating effect on the colour change.

CLINICAL RELEVANCE

The current findings are of importance for clinicians to manage TS reported by patients when a high CP bleaching agent is used.

Can UK undergraduate dental programmes provide training in non-surgical facial aesthetics?

Aim Recently, more and more dentists have found themselves engaging in the delivery of non-surgical facial aesthetics (NSFA) as part of their regular practice routine. NSFA is a growing field in aesthetic medicine that is practised by a range of clinicians including doctors, dentists and registered prescriber nurses and is an industry estimated to be worth over £3 billion in the UK alone. In the past few years, several public scandals in aesthetic medicine have prompted reactions by several bodies including the Government and Royal Colleges. With Health Education England (HEE) having recently released standards in education, it is clear that a shift in attitude towards training is imminent. With a large volume of dentists making up this NSFA workforce it is reasonable to consider the stance of undergraduate training and the relevance of the existing knowledge within dentistry in the context of the HEE standards.Method All dental schools in the UK were contacted to establish the range of subjects taught within the curriculum, with particular reference to those relevant to NSFA. The two largest aesthetic pharmacies were contacted regarding numbers of registered dentists they serve.Results Twelve out of 16 dental schools responded. Two-thirds of responding dental schools do not cover NSFA in their curricula. However, many dental schools cover related subjects including: facial anatomy/material science/neuromuscular junction physiology (100%), anatomy of the aging face (66%), pharmacology of botulinum toxin (25%) and ethical-legal implications of aesthetic dentistry/NSFA (50%/42% respectively).Conclusion Dentists are well placed to deliver NSFA given their background in relevant subjects and surgical training. With the emergence and growth of such a large multi-disciplinary field it is crucial that dentistry is not left behind. Just as most dental schools have embraced the evolution of cosmetic dentistry and implantology, it would be prudent to consider that training standards around NSFA are reflected in both undergraduate curricula and appropriate post-graduate clinical training for dentistry.