Dr Arti Hindocha: Tooth Whitening Protocols During Aligner Treatment. Part One of a Two-Part Series.

Feb 08, 2023

In part one of a two-part blog series, Consultant Orthodontist Dr Arti Hindocha discusses her own protocols and examines the evidence around aligner attachment placement during aligner and tooth whitening treatments.

As the orthodontic industry sees a rise in demand for aligners and whitening, it seems there’s never been a better time to understand whitening and aligner combined treatment packages for adult patients. Whitening is being requested more frequently, especially by orthodontic patients (Slack, et al 2013). Davis et al. (1988) reported that 88% of orthodontic patients asked for whitening during or after their treatment.

Whilst preparing for this article, I noticed conflicting information about the right time to prescribe whitening with aligner cases, and if it should be during or after treatment with aligners. So, if you are considering offering whitening during aligner treatment, and don’t know where to start, it’s hardly surprising.

In this blog, I aim to cut through some of the confusion by sharing the protocols I follow, with success. I also share a simple explanation for patients on what attachments are, how whitening can be successful after, but also before and during treatment, and how a flexible approach to adult patient needs can positively enhance their experience.

How do you explain attachments and their importance to patients?

I explain that an attachment is made with a small piece of tooth coloured material called composite, often I will call them “buttons” or “tabs”.

I explain that not every tooth requires one, but where it is deemed necessary, it will aid alignment of the tooth. It is specially shaped to a certain angle and bonded to the tooth. It is important to specify they will all be removed after treatment or once the desired position has been reached. I mention that they can feel uncomfortable when not wearing the aligner. I reiterate how they are often needed to create movement during aligner treatment. The attachment creates extra pressure against the aligner to help move those teeth that may be rotated or tipped. Some patients will request no attachments on front teeth. If so, I reiterate they may require more aligners but is important to balance the need for attachments versus what the patient wants.

When do you place attachments during aligner treatment?

Starting something new can be daunting and it’s a huge commitment for a patient, including changing daily habits in order to get the most out of their treatment. The aligner cases I take on tend to be complex and involve a high number of aligners; my patients are often in for the long haul. Most of my patients will not have attachments fitted until aligner 6 or aligner 7.

I ease my patients into the aligner treatment by keeping things simple at the start. It is also a good opportunity for them to get into good habits such as reducing snacking and chromogenic substances such as tea, coffee, red wine, and smoking. The key to successful aligner treatment is a commitment to wearing the aligners for the required duration, and in tooth whitening, for the patient to reduce chromogenic substances as much as possible. I find I get the best commitment and motivation if I make the patient experience as comfortable as possible from the start.

Can patients whiten their teeth before attachments, whilst wearing attachments, or after removal of attachments?

Whitening with attachments is controversial and there is currently no evidence base to support it. In each case, I use my clinical judgement and discuss all options thoroughly with a patient. I explain that they can whiten before, during or after treatment. Levrini et al., (2015) suggested that the use of bleaching agents with aligners at the beginning of orthodontic treatment was not recommended as the crowding of the teeth would affect the fit of the tray and the final result of tooth whitening.

I have had patients whiten during treatment with attachments in situ because it was their wish. However, it is not something I recommend as a first option. I have had patients whiten with or without attachments, before, during or after treatment and my patients have been very happy with their outcomes.

If one of my patients wishes to whiten before placement of attachments, I explain they ideally should whiten in the first 2 weeks, utilising the 1st and 2nd tray on 14-day cycles. After tooth whitening, it is said that it takes between two to three weeks for the oxygen free radical particles to dissipate out of the tooth’s surface. As a result, you should wait a minimum of two to three weeks after whitening before bonding attachments. I find my attachments bond well when I place them at aligner 6 or 7, as there is usually a 4–6-week gap, and their teeth have settled. Tooth whitening is done at the start of treatment at the request of the patient and after a thorough informed consent process.

If whitening with attachments, the whitening gel seems to diffuse into the tooth, whitening the enamel underneath the attachment. Sword and Haywood (2020) used an aligner as a bleaching tray in two patients. They aimed to assess the feasibility of having bleaching performed at the same time as orthodontic treatment, without creating non-whitened spots in the areas where the attachment buttons are located. They suggested that home bleaching using 10% carbamide peroxide could be performed concurrently with aligners because the bleaching material had small-molecular-size particles that were able to penetrate the dentine of the areas adjacent to the attachment buttons, without the need for direct contact between the bleaching material and tooth surface to achieve efficient bleaching for these areas.

Whitening is being requested more frequently, especially by orthodontic patients (Slack, et al 2013).

It is important to note that because there is no robust evidence base on the efficacy of whitening with attachments, it is vital to make sure your informed consent process is thorough and patients understand risks and benefits of undertaking tooth whitening. I also reiterate if there happens to be a tooth shade discrepancy/inconsistency, it is possible to reapply the bleaching agent during the retention phase of the aligner treatment, or during additional aligners once most of/all the attachments have been removed from the teeth.

Whitening towards the end of treatment, without attachments, keeps patient motivation high; tooth movements are smaller and the trays still seem to fit well. On occasion, you’ll need to motivate your patient half way through treatment and tooth whitening is also one way of doing so.

The views stated in this article are the views of Dr Arti Hindocha

Arti is working in partnership with DB Orthodontics to raise awareness of good practices for GDPs and orthodontists carrying out both fixed and aligner treatments, as part of a thorough care plan. Her recent presentation “Interproximal Reduction: Best Practice in Easy Slices” offers a comprehensive guide to IPR, including the benefits of a minimally invasive approach.

About Dr Arti Hindocha

BDS(Hons) MJDF RCS (Eng) MClinDent M.Orth RCS(Eng) FDS Orth RCS (Eng) C.I.L.T

Arti Hindocha qualified with Honours from King's College London (2009). She specialised in orthodontics at Eastman Dental Institute and Kettering General Hospital obtaining her MClinDent (UCL) on intra-oral scanning and M.Orth from the Royal College of Surgeons England (2015, 2016). She completed a further two years of higher orthodontic training at the Royal London Hospital and William Harvey Hospital; qualifying as a consultant in 2018, with her Fellowship in Orthodontics from the Royal College of Surgeons. She is currently a consultant orthodontist at Kettering General Hospital and works in 2 private practices in Wimpole Street and Northampton. She is passionate about teaching undergraduates and postgraduates, in her free time she supports and mentors GDPs who have an interest in orthodontics.She lectures locally, regionally and internationally; lectures feature topics such as Interproximal reduction, Autotransplantation, Ectopic teeth, IOTN and referrals.

Arti is currently Secretary of the European Federation of Orthodontic Specialists Association (EFOSA). She will be part of the Consultant Orthodontic Group committee (British Orthodontic Society) from 2023. She has been President of the European Postgraduate Student Orthodontic Society (EPSOS), Postgraduate Representative on the Royal College of Surgeons Board. She is a member of the British Orthodontic Society, British Lingual Orthodontic Society, and the European Orthodontic Society.

References:

Davis, L.G.; Ashworth, P.D.; and Spriggs, L.S. (1998) ‘Psychological effects of aesthetic dental treatment’, J. Dent. (26), pp 547-556. Available at: DOI: 10.1016/s0300-5712(97)00031-6. (Accessed 12 December 2022).

Levrini, L.; Mangano, A.; Montanari, P.; Margherini, S.; Caprioglio, A.; Abbate, G.M. (2015). ‘Periodontal health status in patients treated with the Invisalign (®) system and fixed orthodontic appliances: A 3 months clinical and microbiological evaluation’. Eur. J. Dent., 9, pp 404–410. Available at DOI: 10.4103/1305-7456.163218. (Accessed 12 December 2022).

Slack, M.E.; Swift, E.J. Jr.; Rossouw, P.E.; and Phillips, C. (2013) ‘Tooth whitening in the orthodontic practice: A survey of orthodontists’, Am. J. Orthod. (143), (4 Supp), pp 64-71. Available at: 10.1016/j.ajodo.2012.06.017. (Accessed 12 December 2022).

Sword, R.J.; Haywood, V.B. (2020). ‘Teeth bleaching efficacy during clear aligner orthodontic treatment’. Compend. Contin. Educ. Dent. (41), e6–e11. Available at: https://www.aegisdentalnetwork.com/cced/2020/05/teeth-bleaching-efficacy-during-clear-aligner-orthodontic-treatment. (Accessed 12 December 2022).

About DB Orthodontics

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