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Best Practices for Bleaching your Teeth Right Before Cosmetic Dentistry

Sep 8, 2013
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People who are looking for the perfect smile – or who want to correct or enhance a smile with visible aesthetic issues – are turning to cosmetic dentistry in droves. Through a variety of increasingly sophisticated techniques, smiles are being transformed every day with porcelain veneers, crowns, and composite bonding.

If you're already someone who bleaches their teeth and you're also looking into having "work done," you may be asking yourself some questions about how bleaching and cosmetic dentistry can work together. Often times patients want to achieve whiter teeth through cosmetic dentistry and so they will need to go through teeth whitening prior to a procedure. This guide covers the best practices to bleaching your teeth prior to getting any "work done." We consulted one of our whitening authorities, Dr. Rodger Kurthy, DDS, and he was kind enough to give us his perspective.


Q. I whiten my teeth and will soon be undergoing cosmetic dentistry – do I whiten before or after the procedure?


A. Good question! You should whiten your teeth prior to any cosmetic dental treatment, so the shade/color/translucency of the new cosmetic treatment can be closely matched to the whitened natural teeth.

All newly whitened teeth will "rebound" to some degree after whitening. That means that your teeth will darken very slightly, even after the most successful teeth whitening sessions, and will continue to do so, although at a much slower rate, until your next whitening procedure. The trick is to have your cosmetic dentistry performed at least three weeks after whitening so that your teeth reach a more stable color.

This is very often a significant problem for dentists. Most often, once a patient decides they want a nice smile, they're in a hurry. The patient typically doesn't want to wait long after whitening before they start their cosmetic dentistry. We dentists try to get our patients to "cool their jets" so that the final result is great for the long term.

This problem is compounded by the fact that a high percentage of patients making the decision to have cosmetic dentistry performed, make the decision because of an important upcoming event, such as a wedding, class reunion, family reunion, etc. Most frequently they don't get started with their cosmetic dentistry soon enough, which puts pressure on the dentist to get it done faster than they really should. The term "haste makes waste" is very true when it comes to cosmetic dentistry.


Q. When should I stop whitening prior to cosmetic work?


A. As I mentioned in the previous question, the longer period of time between whitening and having cosmetic dentistry started, the better. If at all possible, in no case should cosmetic dentistry be started any sooner than two weeks after whitening. In my practice I always pushed for AT LEAST three weeks, and even more.

After whitening, it is my belief, and the results of my clinical testing show, that for most patients, wearing their at-home whitening trays with whitening gel once a month is a good idea. But that is just an average. Some teeth tend to rebound/relapse much faster than others, and most often there is no way to know how fast any particular patient will rebound ahead of time.

Some patients (especially tetracycline stained patients) require even more frequent maintenance than once a month, and some only require as little as twice a year.


Q. Do all teeth accept color the same way?


A. When considering this question relating from patient to patient, no, there are very large variations between individuals. Some patients' teeth whiten extremely quickly, and are very simple to get truly WHITE. Other patients have teeth that are very resistant to whitening. There are many reasons (based on various scientific factors that are seen in the teeth from patient to patient) why some patient's teeth whiten more easily or more difficult than others.

When considering this question in terms of comparing teeth within the same patient's mouth, the answer is a bit different. Yes, certain categories of teeth will often whiten differently within an individual patient's mouth. For example, the two upper central incisor teeth will typically whiten almost exactly the same. The two upper lateral incisor teeth will whiten almost exactly the same. In fact, whichever tooth you're talking about in the mouth, it's counterpart on the opposite side of the mouth will typically whiten exactly the same.

Even though there is some difference in structure between the central incisors (the two front teeth) and the lateral incisors (the teeth right next to the two front teeth), these teeth will often whiten exactly the same, or in some situations the central incisors may whiten "almost" the same as the lateral incisors.

On the other hand, the teeth next to the four incisors (the cuspid teeth, sometimes called the "Eye Teeth" or the canine teeth, or even sometimes called "the fangs") are almost always naturally darker in color than the four incisors, and they will most frequently whiten differently than the incisors.

Also, because the lower front teeth have thinner enamel than the upper front teeth, the lower front teeth most commonly do not whiten quite as much as the upper front teeth.


Q. Are any individual teeth more likely to absorb or reject bleach than others?


A. It would be rare for an individual tooth to whiten differently than all the other teeth in the mouth. There are only a few situations where this may happen.

  • If the ">at-home whitening tray fit much better on one tooth, or in one area than in other areas, that tooth or those teeth may whiten better.

  • If a particular tooth has had previous trauma, such as being hit while playing football, etc., the nerve in that particular tooth may recede within the tooth. This would mean that the tooth structure would become thicker inside the tooth, and the tooth may darken. Such a tooth may whiten differently than other teeth.

  • If a tooth has had previous dental treatment where some sort of material has been bonded to the tooth, if the bonding resins have coated the tooth surface, this will impede the whitening gel from getting into the tooth, and could prevent the tooth from whitening as much, or possibly at all.




Q. When and where should the dental lab document my teeth shade?


A. Ideally the shade should be taken immediately prior to the lab starting work on the case. The shade would be most frequently recorded by the dentist or dental staff in the dental office. Occasionally the lab technician who will make the crowns or veneers will come to the dental practice to evaluate and record the shade. And sometimes the patient will actually go to the lab to have the shade recorded under a specific lighting environment. As long as the person evaluating and recording the shade is properly skilled, it does not matter where the shade is evaluated and documented.


Q. What is the best way to document my teeth shade in preparation for cosmetic dentistry?


A. Keep in mind that it is absolutely impossible to exactly match the color of a porcelain crown or veneer to natural tooth structure. Natural enamel is not porcelain. The two substances are not even remotely similar in microstructure. It is possible to get a perfect match between porcelain and enamel in one type of light, where the light is coming from a particular angle, and we are looking at the teeth from a particular angle. But as soon as we walk into another room with a different type of light (fluorescent, incandescent, halogen, LED light, or natural sunlight), we now may be able to see a subtle difference, but most times it is not detectable. Or even in the same lighting conditions, if we look at the teeth from a different angle, we may see a slight difference.

Some dentists or labs will even ask the patient which light they prefer to match the color under. And I believe it is ideal, when evaluating the shade, to have the shade evaluated with the patient in natural sunlight (usually in a shaded area), under fluorescent light, and incandescent light. And even with fluorescent light, fluorescent bulbs come in a white variety of light wavelengths, so teeth can look different under each type of fluorescent bulb wavelength.

A person trained and highly skilled at evaluating shades will try to select a shade that is "middle of the road" between all possible lighting conditions. Nowadays many dentists and labs have electronic instruments that objectively determine the exact shade of the teeth.

Another factor is translucency. The level of translucency of patients' teeth varies widely, and this too must be taken into account when fabricating porcelain cosmetic dentistry.


Q. What if the labs restorations do not match my surrounding teeth during placement? Should the patient reject it?


A. Well…that depends. Dentists and labs may be highly trained and highly skilled. But God they're not. There are physical limitations as I have discussed above, so my following answer assumes that the patient is a normal, rational person. Some patients are so fanatical about certain things that they demand results that are physically impossible.

So as long as the patient is a rational person, and realizes there are some limitations, the patient should request to see the final porcelain restorations on their teeth before they are permanently placed. I would recommend that the patient look at these restorations in natural light (outside in a shady area), in fluorescent light, and in incandescent light if possible. They should also stand in different areas of the room to see how the light angle affects the appearance of the porcelain.

If the patient feels that the teeth do not match the natural teeth as well as they'd like, they should make their feelings known to the dentist immediately. This is a very important step. Once the patient accepts the restorations and the dentist bonds them in place, they cannot be removed without starting the entire case over from the beginning.


Q. Any tips for patients when dealing with the dental labs and dentist when it comes to shade matching after whitening?


A. Do not select a shade too soon after whitening is completed. Never less than two weeks, and if at all possible, three weeks. Even longer than three weeks is advisable.

Looking for bargain porcelain veneers or bargain porcelain crowns is about as smart as looking for a bargain brain surgeon. The very best dentists and the very best dental labs have enormous amounts of training, use the very best materials, they take their time, and they cost more. Never assume you will receive other than fake looking porcelain from a bargain dentist and bargain dental lab.


Q. Is there any risk of newly placed veneers changing shades after placement? If yes, why does it happen? What do you recommend if a shade change is visible?



A. Yes, there is a risk of veneers changing shades after placement. Veneers are most commonly made of porcelain, and porcelain will not change color over time – but there are other factors at work other than the porcelain itself.

It is possible for the resin cement/glue (luting agent) to change shade a short few years after porcelain veneers are placed. This is where the training, talent and experience of your dentist is important. A dentist highly skilled and experienced in cosmetic dentistry will know which products to use, and which not to use.

Ultra-thin porcelain veneers are the current popular fad today. Yes, there are definite advantages to ultra-thin porcelain veneers, such as less necessary drilling on the teeth. However, there are distinct disadvantages to ultra-thin porcelain veneers. If you want to block out the darker color of the tooth underneath the porcelain veneers, and if those veneers are ultra-thin, your only option is to use a very opaque porcelain (which looks very fake), and a very opaque cement/glue/luting agent, which also adds to the fake look of the porcelain veneers. Sometimes dentists will use our KöR Whitening method to achieve a good whitening result so that they can make their ultra-thin porcelain veneers more translucent and natural looking, and still end up with a very light tooth. The problem with this is that once the porcelain veneer is placed, it is impossible to "maintain" the light color of the tooth underneath the veneer. Therefore, year after year, the tooth underneath slowly starts to darken again. It will never go back to the darkness it was prior to KoR Whitening, but it will certainly darken somewhat. Since the porcelain veneer will have been made more translucent, the darkening tooth underneath will show through, and the porcelain veneer will appear to have gotten darker a few years after the porcelain veneers were placed. Some have advocated the possibility of maintaining the whiteness of the tooth underneath the porcelain veneer by whitening the inside portion of the tooth (the lingual side), however our in-depth clinical studies have proven that this notion is a fallacy, and is NOT effective.


Q. What if there is significant whitening relapse with the surrounding teeth after placement of the cosmetic dental work? Attempt to whiten more? Replace dental work? Any first hand experiences encountering this?


A. This is all too common. Some of the time it is because the dentist is in a hurry to do the cosmetic dentistry, and the shade is determined immediately after whitening is finished. But more often it is due to an important event (such as a wedding) rapidly approaching, and the patient pressuring the dentist to hurry the treatment.

Certainly teeth bleaching could be used in an attempt to get the natural teeth even lighter, so that they will match the porcelain veneers/crowns, however the best approach is to not hurry treatment in the first place. Cosmetic dentistry…at least GOOD cosmetic dentistry…is quite expensive. It is meant to last and look great for years and years. It makes no sense to rush cosmetic treatment and run the risk that the final result will be compromised for the life of the restorations.

However, if this should happen, the best solution is to attempt to whiten the natural teeth even more than they were originally whitened. Also, it may mean that this patient must always and forever have a more frequent at-home whitening maintenance schedule to keep the natural whitened teeth as bright as possible.


Q. What if cosmetic dental work yellows/darkens over time? Techniques for rejuvenating the porcelain or removing extrinsic stains? Advanced Techniques for intrinsically whitening the veneered/capped tooth via lingual hole.


A. In general, if cosmetic dental treatment discolors over time, the only true cure is redoing the cosmetic dental treatment. Porcelain typically will not accumulate surface stain more than natural tooth structure. My recommendation for keeping stains from accumulating on porcelain or natural teeth is use of Rembrandt Toothpaste. Rembrandt Toothpaste utilizes an enzyme from the papaya fruit that dissolves organic stain, yet is quite low in abrasiveness.

Though some have advised whitening the underlying tooth via whitening the inside (lingual side) of the tooth, our in-depth clinical studies have proven this to be a total waste of time.

One would NEVER want to drill a hole into the middle of a tooth to whiten the inside of the tooth, because this would raise havoc with the pulp (nerve) of the tooth, resulting most often in the need for a root canal. On the other hand, if the tooth is darkening because it's already had a root canal, then this would be the rare exception where a hold could be drilled into the tooth behind the porcelain veneer to whiten the inside of the tooth. This is referred to as "internal bleaching."


Q. Need to specify how composite/bonding plays a role in this too. Can composite "temps" match the surrounding teeth?


A. 
Composite resin temporary crowns and temporary veneers will often look great – but these materials come in various predetermined shades and translucencies, and cannot be customized for the particular patient. This is usually not a problem because temporary crowns and temporary veneers are just that…temporary. So they are an excellent material that will look good, but usually not AS good as the final porcelain crown or veneer.

If a tooth requires only a bonded composite resin instead of a full porcelain veneer or porcelain crown, this can be a bit of a challenge after whitening. The lighter a tooth is, the more difficult it is to adequately match the shade with a composite resin. Again, this is where the training, skill and experience of the dentist come into play. If a dentist does not do a lot of cosmetic dentistry, he or she will likely not have a wide variety of bleaching shade composite, and may not have one that will match the particular patient ideally. On the other hand, the dentist who does a lot of teeth whitening and other cosmetic dentistry will probably have just about every shade and brand of bleaching shade composite on hand, and therefore most often be able to match the shade of each individual patient very well.


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