Hydrogen Peroxide vs Carbamide Peroxide for Bleaching Teeth: Which one works better for your patients?

My offices often ask me,  “What is the difference between carbamide peroxide and hydrogen peroxide, and which one works better for teeth whitening or tooth bleaching?” I've found that the Whiter Image products are unique becuse they add Carbamide Peroxide to Hydrogen Peroxide in most of their products, to give your patients the added benefits of both fast whitening action and anti-sensitivity.

Carbamide peroxide (CH₆N₂O₃), also called urea peroxide, urea hydrogen peroxide (UHP), and percarbamide, is an adduct of hydrogen peroxide and urea.

Carbamide peroxide is mainly used as a disinfecting and bleaching agent in cosmetics and pharmaceuticals. As a drug, this compound is used in some preparations for the whitening of the teeth.

In tooth bleaching, the hydrogen peroxide produced acts to oxidise extrinsic staining within tooth enamel. There are several methods of applying the peroxide gel to the tooth ranging from night-guard application at home or in-office application. The bleaching obtained is proportional to the length of time the peroxide is applied to the tooth, and the concentration used. Concentrations used for tooth whitening purposes range between 10% and 36%. Higher concentrations may carry a higher risk of side effects such as chemical burns of the gingiva and lips.

The actual teeth bleaching procedure is still accomplished by placing a peroxide-based (either hydrogen or carbamide) bleaching gel, via various methods, into direct contact with the teeth. This contact of bleach to teeth is made either by painting the gel directly onto the teeth or using the custom tray method. It has been shown that these two techniques will result in noticeable whitening of the teeth. The finished degree of whitening ultimately achieved is predicated on the relative type, the strength or concentration of the peroxide-based gel that is used, as well as the amount of time that the active gel is left in contact with the surface of the teeth.

If the concentration is low, a longer amount of contact time against the teeth with the active bleach is needed to achieve a satisfactory result. This meant that for the patient a number of daily treatments were needed either in the dental office or at the patient’s home for the teeth to become satisfactorily white.

Making the teeth bleaching gel concentration stronger, on the other hand, would speed the color change, but would often lead to increasingly painful tooth sensitivity, which was a very non-desirable result for both the patient and practitioner. So, industry experience has been that a good result could be obtained at home if the patient used either a medium peroxide concentration of bleaching gel coupled with a regimen of spacing the treatments into an hour or less per day for a number days to a week.

When you get your teeth whitened, the hydrogen peroxide component  is what actually whitens them. Tooth bleaching today is based upon hydrogen peroxide (HP) as the active bleaching agent. Hydrogen peroxide is a relatively unstable molecule by itself, and will quickly disassociate into highly reactive, strong oxidizing agents through the formation of three types of free radicals (hydroxyl radicals, per-hydroxyl radicals, and superoxide anions), reactive oxygen molecules, and hydrogen peroxide anions.  In all of these free radicals, it is the highly unstable free oxygen component in each that reacts with, oxidizes, or if you will, attacks the long-chained, dark-colored chromophore molecules, the atoms or groups in a molecule that cause discoloration, in the patient’s teeth enamel. This attack splits the chromophore molecules into smaller, less colored, and more dissolvable molecules, which results in whitening of the teeth. It doesn’t really remove any stain, but it actually changes the nature and composition of the stains on the teeth. The final results of the bleaching treatment depends mostly on the concentration of the Hydrogen Peroxide available to produce the free radicals, on the amount of time the produced radicals are in contact with the teeth, and the ease in which the radicals can reach the chromophore molecules

Hydrogen Peroxide, in a gel substrate, may be applied directly to the teeth, or it can be produced in another chemical reaction from the more stable Carbamide Peroxide (CP) in the presence of water. Carbamide peroxide has two portions, the Carbamide portion and the Hydrogen portion.

Even if you are using carbamide peroxide, what actually whitens your teeth is hydrogen peroxide. Something that many people don’t know is that carbamide peroxide is made from hyrdrogen peroxide. To create carbamide peroxide, a urea molecule is added to the hydrogen peroxide molecule and the result is carbamide peroxide. Please note that there is a 3:1 relationship between carbamide and hydrogen. For example, 12% hydrogen peroxide is theoretically equivalent to 36% carbamide peroxide. However, this doesn’t mean that you’ll get the same results with 36% carbamide and 12% hydrogen peroxide. Carbamide Peroxide takes more time, but Carbamide Peroxide is much more stable than Hydrogen Peroxide and also has a much longer shelf life.

In order for carbamide peroxide to whiten your teeth, it must first break down into hydrogen peroxide. The problem in using carbamide in chair-side treatments that are 15 to 20 minutes is that it takes at least 15 minutes for carbamide peroxide to begin to break down into hydrogen peroxide (and longer to completely break down). Only when the carbamide peroxide has broken down into hydrogen peroxide can it begin to whiten your teeth. So if you use carbamide peroxide for teeth whitening during a 20-minute treatment, your customer will only have a little hydrogen peroxide on his/her teeth for 5 minutes. That’s why most people that use carbamide peroxide are using it for take-home whitening or to prevent sensitivity. Carbamide peroxide has been used traditionally for patient's with difficult stains and sensitivity such as tetracycline-stained teeth, because the patients needs a much higher level of hydrogen peroxide but doesn't want sensitivity.

Most teeth whitening suppliers choose to use carbamide peroxide because it causes less gum irritation than hydrogen peroxide.  When a fast single-treatment in one-hour-or-less is not being done, and one wants to design a take home teeth bleaching kit that is safe and very forgiving of consumer mishandling, Carbamide Peroxide is the better choice. It is much more stable and takes longer to react than Hydrogen Peroxide. It has a longer shelf life since it needs to come into contact with water before it starts to react, whereas Hydrogen Peroxide can start to react by being over-exposed to the in-office light energy.

The last factor involved in the Carbamide Peroxide versus Hydrogen Peroxide debate is that of using a very bright, blue light, in the visible spectrum, to accelerate the reaction. Does one form of peroxide or the other work better with an accelerator light? It has been shown that using a light can aid in the bleaching process that results in whiter teeth in less time.  Also, it is also seen in the literature, that by examining the studies of the light being used in teeth bleaching, it is always used with hydrogen peroxide instead of carbamide peroxide. It appears that the added light energy of visible light at 480-520 nanometers (visible spectrum blue light) helps increase the energy of activation of the peroxide molecule to form its free radicals. Carbamide Peroxide first has to break down into carbamide and hydrogen peroxide, so it takes longer for the chemical combination to become ready to accept the light’s extra energy input to help activate or catalyze the breakdown of the Hyrdrogen Peroxide into its bleaching-capable free radicals.

Looking for products with COMBINED hydrogen peroxide and carbamide peroxide for both strength and quick uptake of whitening and for anti-sensitivity? Check out the Whiter Image whitening line through Dental Girl (www.dgdentalgirl.com) or call or email your Dental Girl representatives at linda@dental-girl.com for more info.

 

 

 

 

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Holistic Wellness in Dental Offices: The Amethyst BioMat

The dental experience is starting come full circle, evolving from a once feared and painful experience into a relaxing pseudo-spa visit. With the promise of meditation rooms, green dental materials and hand and foot massages while undergoing treatment, your dental patients are expecting to find the equivalent of the Camelback Spa experience while simultaneously undergoing major reconstructive dentistry. Are you an RDH, EFDA, RDA or are you a massuese/spa caregiver? Should you be greeting your patients with lavendar-scented neck wraps or talking to them about brushing and flossing? The truth is, your office is probably evolving into both a medical surgi-center and a holistic retreat, complete with waterfalls, chair massagers and the latest in spa technology.

What started all of this? Dentists, in an effort to increase their bottom line, are attending seminars to learn the latest technology, to hone their surgical skills, to discuss the complications of implant failure ad nauseum, and then running back to their offices preparing for the onslaught of new patients to arrive, but generally it doesn't just "happen"? The office must be marketed correctly; it must be perceived as being on the cutting edge of not only skills/expertise but of comfort and aesthetics as well. Literally, dental patients shopping for aesthetic and cosmetic treatments are looking to be wooed, and the most successful offices are starting to combine holistic treatments like meditation music, negative ion bracelets and amethyst biomats into their procedural options.

Where does the Amethyst BioMat fit into this scenario?  We've been reading about them for years in the context of spas and alternative medicine and now they're infiltrating into the medical/dental office. Imagine this...patients receive local anesthesia while reclining in a "meditation room" listening to calming waterfalls, wearing heated neck wraps, receiving a hand massage all while lying on a heated biomat of amethyst crystals designed for medical offices.  These infrared heated mats are known for reducing stress, relaxing muscles, and relieving arthritic pain, not to mention boosting their immune systems, burning calories, and increasing the appearance of the skin by encouraging cell turnover. Did I mention that Amethyst Biomats even claim to increase sexual performance by improving circulation? Tell that to your implant patients on their next visit.

The Richway Biomat company, just one manufacturer of the Amethyst BioMat, describes their mat as delivering Negative Ions, which are said to energize the body for optimal health. The Negative Ions delivered through the BioMat are delivered directly to the body through the skin’s surface via conduction by refracting infared light through amethyst crystals, known for their calming and healing properties, in a process known as Far Infared Crystallography (FIR).  The direct conduction of negative ions through the BioMat (or even thrugh negative ion bracelets as we discussed in an earlier blog entry) allows for an immediate response and change in the body's electrical field for 100% of the people, whereby cell channels are activated for a rapid return to the body's optimal physiological state.  Their web site goes in to explain that FIR refracted through amethyst crystals organizes the FIR into geometrical patterns with higher bio-compatibility, allowing them to penetrate penetrate 6-8 inches into the human body, benefiting the skin and muscle tissue on the surface of the body as well as into deeper tissues of the lymph glands, blood vessels, nerves, as well as key organs.  Using an Amethyst BioMat in any setting, including a home, spa or office provides a variety of holistic and anti-aging benefits such as Improved Circulation and Cardiovascular Function; Improved Immune System Function; Relieving Pain by dilating blood vessels and increasing circulation; Easing Joint Pain; Relieving Stress and Fatigue; Improving Skin Cell turnover and Detoxification. Sounds great, doesn't it, like a massage in a box? But how can this help our dental patients?

How many patients in your office are putting off their full mouth restorations due to their fear of dental procedures? Real or imagined, they have very real concerns about coming to your office, no matter what your fees or expertise may be. Imagine creating a haven of relaxation where your patients slip on Negative Ion bands in the waiting room and look forward to a 30-60 minute session on the Amethyst BioMat which you can advertise  as offering preventive and restorative healing through pain reduction, increased mobility, disease prevention, and total mind and body relaxation.  Even a short time on the Biomat reduces stress, muscle tension and aches and pains.  The websites say that BioMat patients feel like their receiving a spa treatment in the comfort of their dental office.  In terms of healing properties in conjuction with dental procedures, new studies also suggest that Biomats establish more balanced pH levels in the body, improves cellular absorption of oxygen and nutrients, restores hormonal balance and improves lymph flow and endocrine production. The lymphatic system delivers nutrients and oxygen to the cells of the body, and removes cell waste, while the endocrine system regulates hormonal uptake in our bodies, which controls everything from our mood, tissue growth and health to metabolism and sexual and reproductive functions.  From both an emotional and a medical perspective, adding negative ion components to your office such as the Amethyst BioMat can only enhance your patients dental experience while providing a safe holistic spalike treatment that may cause them to choose your office over the office nextdoor.  All I know is that this Dental Girl is anxious to try the Amethyst BioMat!  Happy Friday!

Long Term Success of Dental Implants

Hello Dental Girls!

As you approach the holiday weekend,  you're thinking of cookouts on the beach and Limoncello Martinis in your not-so-distant future,  but you still have a few patients left to see before making a mad dash to the Hamptons (or in lieu of the Hamptons, perhaps, your local swim club).  You've raced to the office, checked your hygiene schedule and there it is. You're confronted by a recall patient, a smoker with diabetes and perio and a variety of triggers, both genetic and external,  that are upregulating their cytokines and inflammatory mediators, who has had an implant placed in the posterior maxilla and you've been noticing inflammation, pocketing and exudate.  How do you treat this particular patient and specifically the implant which is starting to present with signs of peri-implantitis? Which products, instruments and protocols will be best for the natural teeth as well as the implant?

I posed this question to another one of Dental Girl's resident experts, Dr Gregori M. Kurtzman,  and he provided us with his updated Protocol for Implant Maintenance, which differs slightly from our last protocol, presented by Dr Robert Delie.

"The key to long term success with implants is how they are maintained and cared for both by the patient and during routine hygiene appointments. We will address some do's and don'ts to make implant care a success, " Dr Kurtzman told me and suggested that I post his protocol so that everyone can benefit from his years of expertise. I think that Dr Kurtzman's protocol will definitely provide food for thought over the holiday weekend, as we continue to search for support and protocols to help navigate the treacherous world of maintaining our implant patients and keeping them in the practice. Here is Dr Kurtzman's protocol and words of wisdom:

IMPLANT MAINTENANCE PROTOCOL

Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA

·        Recall

o   1 week post restoration (check occlusion)

o   1 month post restoration (check occlusion)

o   3 month post restoration (check occlusion and soft tissue as well as pt home care)

o   6 month recall schedule (unless perio dictates more frequent)

·        Radiographic Exam

o   Evaluate Crestal Bone Loss

§  PA radiograph annually (standardized radiographic positioner with bite to get exact position each recall)

·        Clinical Exam

o   Marginal Tissue Evaluation

§  Color (pink, red, cyanotic)

§  Consistancy (firm, boggy, swollen)

§  Comparison to adjacent areas

§  Keratinization

§  Recession (stability of the gingival margin)

o   Inflammation

§  Bleeding Evaluation

·         Probing  (do not probe due to fiber orientation)

·         Digital palpation of gingival tissue to evaluate presence of bleeding or exudate

o   Mobilty

§  Prosthetics

§  Implant fixture

·        Hygiene

o   Absence of inflammation with stable bone level (without fixture collar exposure)

·         Prophy

·         Hand scalers/curettes (plastic, graphite or titanium)

·         Ultrasonic with plastic tip (optional)

·         Do not probe around fixtures due to fiber orientation compared to natural teeth

·         Polish with prophy paste

·         Check occlusion

·         Recall 6 months

o   Presence of inflammation with stable bone level (without fixture collar exposure)

·         Prophy

·         Hand scalers/curettes (plastic, graphite or titanium)

·         Ultrasonic with plastic tip

·         Do not probe around fixtures due to fiber orientation compared to natural teeth

·         Polish with prophy paste (avoid air polishers)

·         Check occlusion

·         Recall 3 months

o   Presence of inflammation with fixture collar exposure

·         Prophy

·         Hand scalers/curettes (plastic, graphite or titanium)

·         Ultrasonic with plastic tip

·         Do not probe around fixtures due to fiber orientation compared to natural teeth

·         Polish with prophy paste (avoid air polishers)

·         Check occlusion

·         Recall 3 months (if inflammation present still at next recall may wish to flap to clean or refer to periodontist to have treated more aggressively)

·         Supplement home care with:

o   CHX rinse

o   Brush on FL2

o   Doxycycline 20mg 2x daily till next recall (Periostat or generic equivalent)

o   Bone Loss with absence of inflammation

·         Prophy

·         Hand scalers/curettes (plastic, graphite or titanium)

·         Ultrasonic with plastic tip

·         Do not probe around fixtures due to fiber orientation compared to natural teeth

·         Polish with prophy paste (avoid air polishers)

·         Check occlusion

·         PA radiograph to monitor bone level

·         Recall 3 months (follow-up radiograph to check stability of bone level)

·        Bone Loss with presence of inflammation (no mobility to fixture)

More aggressive approach needed to stop the bone loss progression, monitoring tends to allow progression and potential loss of the fixture.

·         PA radiograph with reproducible bite on holder

·         Flap procedure to eliminate any debris (calculus, cement etc) subgingivally)

·         Hand scalers/curettes (plastic, graphite or titanium)

·         Ultrasonic with plastic tip

·         Treat exposed threads with Meffert technique for ailing implants*

·         Osseous graft placed to cover all exposed threads (resorbable membrane recommended under flap before closure to allow better organization of the osseous graft)

·         Close with resorbable sutures (PGA recommended)

·         Check occlusion

·         2 week suture removal

·         PA radiograph with reproducible bite on holder at 8 weeks to verify new bone level

·         Recall 3 months

·         Supplement home care with:

o   CHX rinse

o   Brush on FL2

o   Doxycycline 20mg 2x daily till next recall (Periostat or generic equivalent)

·        Bone Loss with presence of inflammation and mobility to fixture

Poor prognosis, implant needs to be removed and site grafted before new fixture

be placed.

·        Implant Complications & Intervention

§  Peri-implantitis defined as the presence of inflammation with or without bone loss at an implant fixture.

·        Unless the inflammation is controlled bone loss will progress with eventual failure of the fixture.  Watching and waiting only demonstrates increasing bone loss and a more aggressive approach is needed to stop the ongoing process

§  Ailing vs failing:

·        Ailing implant is defined as an implant that has some bone loss and inflammation but the absence of any mobility to the fixture with sufficient bone level to maintain the implant long term if the bone were to remain at the current level

·        Failing implant is defined as an implant that has mobility and/or sufficient bone loss that long term stability can not be maintained

§  Criteria for failure

·        Presence of any mobility to the fixture (need to differentiate fixture and prosthetic mobility) signifies a failing implant

·        Insufficient bone support to manage the occlusal loads present

·        Loss of bone level creating an esthetic issue that can not be grafted to restore the implant to proper esthetics

Avoid:

o   Air polisher (may cause air embolism due to weaker connective tissue connection then found around natural teeth)

o   Probing (can inoculate bacteria into sulcus due to weaker connective tissue connection and lack of fiber barrier allows probe to penetrate till bone encountered giving false reading on pocket depth)

o   Stainless steel instruments (harder then implant surface will gouge the implant surface leading to rougher area which will trap plaque)

o   Ultrasonic/piezo tips (the metal tips will gouge the implant surface, if used should have plastic tip)

*Meffert Technique for Ailing Implants

o   Flap tissue to exposure all supracrestal exposed threads on the implant

o   Remove all granulation tissue on the implant surface using titanium scalers

o   Detoxify the exposed implant surface 

§  Make paste from a capsule of Doxycycline (add drop or two of saline to make paste)

§  Apply paste to implant surface only (acidic so avoid contact with bone if possible)

§  Allow to sit 1 minute then rinse

§  Repeat two times

§  Apply citric acid gel to implant surface and bone

§  Allow to sit 1 minute then rinse

§  Repeat two times

§  Modification may be to apply ozonated water to rinse and ozonated oil to the implant surface as final treatment

o   Site is ready for grafting

Gregori M. Kurtzman, DDS, MAGD, FAAIP, FPFA, FACD, FADI, DICOI, DADIA

Dr. Kurtzman is in private general practice in Silver Spring, Maryland and is a former Assistant Clinical Professor at the University of Maryland, Department of Endodontics, Prosthetics and Operative Dentistry. He has lectured both nationally and internationally on the topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed prosthetics, Periodontics and has over 250 published articles. He is privileged to be on the editorial board of numerous dental publications, a consultant for multiple dental companies, a former Assistant Program Director for a University based implant maxi-course he has earned Fellowship in the AGD, AAIP, ACD, ICOI, Pierre Fauchard, Academy of Dentistry International, Mastership in the AGD and ICOI and Diplomat status in the ICOI and American Dental Implant Association (ADIA). Dr. Kurtzman has been honored to be included in the“Top Leaders in Continuing Education” by Dentistry Today annually since 2006. He can be contacted at dr_kurtzman@maryland-implants.com.

Go to www.dentalgirl.net to see more Bios and Protocols  of Dental Experts...

Happy 4th Everyone!!

Dental Implant Maintenance Protocols

Hi Dental Girls!
As I call on my long-standing dental customers, one thing I hear over and over is "how do I handle implant maintenance?"  From the doctor to the RDH to the support staff, everyone has questions. If you're an RDH in the GD office, you may have sent your patient to an OMS or Periodontist or Prosthodontist to have the implant(s) placed, but now that patient is back in your office for recall visits and you are treating them. You're wondering about scalers and adjuncts to keep that implant healthy. As a doctor or as an RDH, you're wondering about the parameters of health for the implant, which are different from a natural tooth. Peri-implantitis, which "looks" like periodontal disease around an implant versus a vital tooth, can be confusing to the dental office.

Do we probe around an implant in the same way that we would with a natural tooth and if so, what do we do when we find inflammation or deep pocketing? When we are scaling around an maxillary arch, for example, and we discover that pocketing around a natural tooth is also surrounding an implant, do we use the same "bag of tricks" we typically use for perio patients? Chlorhexidine, LAA's, home care, interproximal brushes, tissue stimulators? How does hygiene for natural dentition vary from hygiene for implants? Do we utilize an LAA like PerioChip or Atridox, which isn't technically indicated for peri-implantitis but is indicated for PD greater than 4mm, and is an adjunct for SRP, which may be gong in simultaneously? What do we do about bone loss? When is an "ailing" implant truly a "failing" implant? The answers to these questions are varying opinions and they form the basis of Implant Maintenance Protocols.

I contacted several leading experts in the area of Implant Maintenance and I asked them share their personal protocols for treating these types of patients. On my web site, www.dentalgirl.net, there is a tab for Protocols and one for Speaker bios, so feel free to go to it and review the protocols of our thought-leaders. Some of the Dental Experts presented there are available as speakers for your organization as well.

Robert Delie DMD, MDS Dr. Robert Delie is a Clinical Assistant Professor of Periodontology and Oral Implantology at the Kornberg School of Dentisty, Philadelphia. Dr. Delie is a graduate of the University of Pittsburgh, and received certification in Advanced Dental Implantology and a Postgraduate Certificate in Periodontics. He has practiced for over 15 years in periodontics/implantology in numerous offices in Philadelphia. Dr Delie is also the Director of the Residency program at Sacred Heart Hospital and he is available for lectures on a variety of topics.

Dr Delie has trained many GD's through the Residency program yet he actually practices periodontology, so he had a unique perspective as to the needs of the GD as well as the specialist. Dr Delie's biggest concern was bone loss and when the implant has officially "failed" i.e. when should the implant be removed, the site grafted with bone material, wait accordingly, and start with a new osteotomy site versus maintaining the "ailing" implant?  Some of the other KOL's were more geared towards the hygiene maintenance in a GD setting, keeping the fixture healthy and doing anything possible to save the implant, so you'll find varying opinions on what constitutes a healthy implant and what does not, and what parameters warrant removal of a failing implant.
Here is Dr Delie's personal Protocol for Implant Maintenance:

 

IMPLANT MAINTENANCE PROTOCOL

Robert Delie, DMD, MDS

 

·        Recall

o   One year

·        Radiographic Exam

o   Evaluate Crestal Bone Loss

§  PA X-Ray Annually

§  3-D

·        Clinical Exam

o   Marginal Tissue Evaluation

§  Color

§  Consistency

§  Keratinization

o   Inflammation

§  Bleeding Evaluation

·         Probing (BOP)

·         Prophy brushes  (TePe)

·         Interproximal brushes

·         Tissue Stimulators

·        Hygiene

o   Healthy Bone Level (without fixture exposure)

·         ProphyàWNL

·         Hand scalers/curettes

·         Ultrasonic

·         Supragingival or sulcular (abutment) margin

·         Home care products: TePe interproximal brushes, antiseptic rinses

o   Bone Loss (exposed fixture surface)

·         Titanium Scalers

·         Plastic instrument

·         Graphite instruments

·         Irrigation

·         Locally-delivered anti-microbials

·         PerioChip (chlorhexidine gluconate)

o   Home care products: TePe interproximal brushes, anti-microbial rinses

·        Bone Loss (without exposed fixture surface)

·        Without Presence of Bleeding

§  Treat as a healthy site

§  Increase recall and radiographs to every 6 months

·        Presence of Bleeding

·         Subgingival Scaling

·         LAA’s (locally-applied anti-microbials)                               

·         PerioChip (chlorhexidine gluconate)

·        Implant Complications & Intervention

§  Peri-implantitis

§  Criteria for failure

I'll be sharing more protocols from other experts in upcoming blogs. Happy Friday!

Check out all the Protocols on www.dentalgirl.net