Patient Presentation
A 10-year-old female came to clinic for her health supervision visit. She previously had some body image problems because she was overweight and when the nurse checked her in, she had told her that she doing “…lots of things to make me pretty” and had mentioned using dental whitening strips on her teeth. She was excited to discuss self-grooming activities including manicures, pedicures and coloring her hair, and said that she had started to do these things for about 6 months. During the physician interview she noted that she was exercising more, not drinking soda pop and trying to eat more fruits and vegetables. The physician determined that she did have a primary care dentist but had not seen her for more than 2 years. The patient denied any active bullying at school or elsewhere. The past medical history showed her being overweight or obese since age 3 years. The family history was positive for obesity and type II diabetes in the family. The review of systems was negative.
The pertinent physical exam showed her vital signs were normal and her BMI for age was >>95% but her weight gain had been less over the past year than previous years. HEENT showed slightly mid-aligned teeth that did not appear to be overly discolored. She had some intact dental restorations but no obvious active caries. She had a normal thyroid and no acanthosis nigricans on examination. The laboratory evaluation for obesity screening was normal including lipids, hemoglobin A1c, glucose, liver enzymes and thyroid testing. She had a normal hemoglobin also.
The diagnosis of an obese female who was making some lifestyle changes was made. The physician encouraged the lifestyle changes especially the increased exercise and changes in food intake. He encouraged her to not use carbonated beverages, teas and coffee that could potentially stain her teeth. “If your parents let you, I think doing the manicures and pedicures are just fine. Just don’t do real false nails because that can cause other problems like fungus infection or burns because of the nail products. The teeth whiteners I don’t think are a good thing for you too at your age. I don’t know that there is a specific age that is safe but your dentist could tell you and you are overdue see him or her now. Why don’t you stop using the whitening strips until you can talk with the dentist and then do what he or she says. Taking care of your teeth and your body are the best things you can do to keep your body healthy and your smile pretty. Just remember that its okay to want to look nice on the outside but what really counts is what is inside you. Your inner beauty is what really counts.”
Discussion
The appearance of the teeth and mouth is part of what determines facial attractiveness which plays an important part in social interactions. It has been found that “…an aesthetically pleasing smile…depend[s] on tooth color, size, shape, and position, upper lip position, visibility of the teeth and amount of gingival display.” The attractiveness is obviously complex, but tooth color is one of the most important factors and most people would like pearly white teeth.
Dental “…”whitening” is any process that will make teeth appear whiter.”
Non-bleaching products work to remove surface stains by physical or chemical action (usually dentifrices), and bleaching products which contain peroxide to remove surface or deep tooth stains. The bleaching products come in different forms including those placed into a tray around the teeth, painted on, or bleaching strips. The main bleaching products are hydrogen peroxide or carbamide peroxide (which breaks down into hydrogen peroxide and urea). Over the counter (OTC) bleaching agents often contain approximately 10% carbamide peroxide which is equivalent to ~3% hydrogen peroxide. OTC bleaching agents are intended to be used over 2-4 weeks for results and have a lower cost. There are professional products that are designed for home use with a dentist’s oversight with higher concentrations of bleaching agents. Professional products used in the dental office often have higher concentrations of hydrogen peroxide (25-40%) and can be completed in much less time (often 1 visit) but have a higher cost.
Peroxide is considered safe and effective in adults for tooth whitening but there is less data for children and adolescents.
There is at least 1 on-going, randomized clinical trial of dental bleaching in adolescents as of this writing. The most common side effects of dental bleaching are tooth sensitivity and tissue irritation especially in early treatment stages. These problems usually resolve with discontinuation of the product, often within 24 hours. Ill-fitting trays also can cause tissue irritation. Leakage around dental restorations or root problems (ankylosis and resorption) have also been noted. Use of at home products have the potential for abuse (used longer or more frequently than recommended) especially as it can be difficult for a parent to oversee the application.
Regularly scheduled dental examinations are always recommended as part of overall health. A dentist can help to evaluate any dental clinical concerns such as existing restorations, braces/appliances, and reasons for tooth discoloration. A dentist can provide the whitening treatment if recommended, or help to oversee a home treatment plan.
According to Lee et.al. in a 2005 review, conditions that should be resolved or considered before dental bleaching include:
“1. dry mouth;
2. enzymatic disorders;
3. respiratory or digestive tract disorders;
4. asthma;
5. allergy to vinyl;
6. hypersensitivity to hydrogen compounds;
7. mouth breathing;
8. unrestored tooth decay;
9. frankly exposed root surfaces;
10. broken teeth;
11. severe enamel erosion due to acidic or carbonated drink intake or gastric regurgitation (eg, bulimia);
12. parafunctional grinding;
13. poor oral hygiene.”
Learning Point
Tooth coloration is different in primary and permanent teeth because the dental enamel thickness is different.
The American Academy of Pediatric Dentistry says that full arch bleaching when a child has mixed dentitia is not recommended as this “…would result in mismatched dental appearance once the child is in the permanent dentitia.”
According to the 2005 Lee et.al. review, the authors recommend to avoid using home whitening treatment until patients are 14-15 years of age to avoid possible abuse of the products and potential toxicity. They recommend to use custom-fabricated dental trays to decrease the overall amount of product needed, and use < 0.5 gm of a 10% carbamide peroxide whitening gel for ~10 teeth.
Questions for Further Discussion
1. What causes tooth discoloration?
2. What are indications for dental consultation?
Related Cases
Disease: Tooth Bleaching | Cosmetic Dentistry | Obesity in Children
Symptom/Presentation: Health Maintenance and Disease Prevention
Specialty: Dentistry / Orthodontia | General Pediatrics
Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Cosmetic Dentistry
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Lee SS, Zhang W, Lee DH, Li Y. Tooth whitening in children and adolescents: a literature review. Pediatr Dent. 2005 Sep-Oct;27(5):362-8.
Donly KJ, Segura A, Sasa I, Perez E, Anastasia MK, Farrell S. A controlled clinical trial to evaluate the safety and whitening efficacy of a 9.5% hydrogen peroxide high-adhesion whitening strip in a teen population. Am J Dent. 2010 Oct;23(5):292-6.
Tin-Oo MM, Saddki N, Hassan N. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health. 2011 Feb 23;11:6.
American Dental Association. Statement on the Safety and Effectiveness of Tooth Whitening Products. April 2012. Cited 1/19/16
Pinto MM, et.al.. Tooth whitening with hydrogen peroxide in adolescents: study protocol for a randomized controlled trial.
Trials. 2014 Oct 14;15:395.
American Academy of Pediatric Dentists. Policy on the Use of Dental Bleaching For Child and Adolescent Patients. Available from the Internet at http://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf (rev. 2014, cited 1/19/16).
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital