Styleitaliano Dental Bleaching Protocol, Part I: Say hello and take color
Do you need a protocol to document dental bleaching? Read the following tips that will probably help you getting to a better clinical practice workflow.
Tip 1: We say that the first thing to do when a patient arrives is to take color. In your right hand you should shake the one of your patient, while in your left hand you should be already holding your chosen shadeguide: say hello and take color.
Tip 2: It would be logical to dispose the shadeguide depending on brightness as dental whitening increases the luminosity of the teeth.
Tip 3: Start with the upper arch for phycological reasons; the patient will appreciate the difference in color after a few days of treatment which is encouraging and motivating.
Tip 4: Obtain photographic documentation of the initial and final situation with a shade guide; you’ll see this has many reasons.
Tip 1 – Say Hello and take color
One of the effects of teeth dehydration is that it makes teeth appear whiter than they really are. With the lip retractors we should take color as soon as possible because dehydration start from the first moment we place the lip retractor and dry saliva with our air-water syringe. “Say hello and take color” means that color has to be taken at the very beginning, before dehydration takes place.
We get angry when we forget to take color at the beginning of an appointment because dehydration of teeth can alter their shade and may lead to errors in shade matching (1). The air replaces the water between the enamel rods , changing the refractive index that makes the enamel appear opaque and white. Teeth dehydrates and color changes. Rehydration takes time, usually longer than 2 hours (3)
Tip 2 – Dispose the shadeguide depending on luminosity
Our favorite shadeguide is VITA Bleachedguide 3D-MASTER® . Human eye is very sensitive to slight changes in luminosity thats why exist in the market specific shadeguides made only for color taking in bleaching procedures. These scales have many samples, more that the usual shadeguides made for prosthesis or conservative dentistry, with very light changes in value or luminosity. Remember that dental bleaching increases luminosity, has a little effect on chromaticity and almost no effect on tonality.
A SHORT REVIEW OF HUE, CHROMA, AND VALUE
Hue is the attribute of color that allows to classify it as red, yellow, green, blue, or an intermediate between any contiguous pair of these colors. In the Vita shadeguide hue is defined as A, B, C, D. Dental bleaching doesn’t affect the hue.
Chroma or saturation describes how intense is a specific color is. In the Vita Shade Guide chroma is indicated with numbers, being 1 the less chromatic color and 4 the more intense. Bleaching slightly affects the chromaticity, while it reduces the yellowness. (4)
Value is the level of brightness from black to white and is typically not represented at all in the shade selection process. However, value is the most important component when performing bleaching, but also in restorative dentistry. Dental bleaching specially affects the value increasing it, making teeth look brighter.
Classical Vita Shade guide is classified by hue or tonality.
Classical Vita Shade guide classified by value. It is strongly suggested to classify one of your Classical Vita Shade guides for bleaching purposes but it is also convenient for restorative and prosthetic dentistry.
The VITA Bleachedguide 3D-MASTER is the best way to plan and monitor tooth whitening processes.
– It determines the level of luminosity during bleaching in only one step.
– The clear organization supports communication between dentist and patient.
– Realistic representation of the bleaching procedure and simplicity thanks to an easy and comprehensible structure.
In the above picture you can see the Vita 3D-MASTER Bleached guide (5) with tabs based on the brightness levels defined by the American Dental Association; this facilitates an accurate recording of grades in the bleaching process. When it comes to documenting shade changes, the VITA Bleached guide 3D-Master is the only linearly-aligned shade guide that has the ability to properly document the changes systematically. Due to the equal-distanced shade tabs, it is easy to perceive color shifts and accurately depict equal shade shifts between each shade tab. Shade guides are typically not scientifically fabricated to have each of their shade tabs the same distance away from each other in 3-D color space. Some shade tabs look very similar to their neighboring shade tab, while others look drastically different. This deviation of color can be a drastic difference, or a very minor (almost undetectable) change between shade tabs. This can make the shade analysis and selection process very difficult. (6)
Even if for a more detailed and precise color project and control over the bleaching procedure, we advise you use the dedicated VITA Bleached guide 3D-MASTER shades. 3 Bleached shades are available as a supplement for the VITA Classical guide, for those who would like to stick to that system for dental bleaching. These VITA Bleached Shades include shades 0M1, 0M2 e 0M3, which are integrated into the VITA SYSTEM 3D-MASTER
Tip 3 – The upper arch first
We always want to bleach the upper arch first, as a protocol, during the first week. For tooth whitening it is a fact that, for a patient, it is fundamental to be able to notice a difference induced by our treatment; this is only possible by comparing the colour of the teeth after the treatment with the colour before the treatment. If we take into account the imperfection of human colour memory we should better bleach the upper arch first. If you perform bleaching in you daily practice probably happened to you that patients don’t remember the initial color and think that bleaching doesn’t work and you have to show the initial picture.
In our experience, if we bleach the upper arch first, we are helping the patient to appreciate the difference in color and we encourage and motivate him/her to continue with the bleaching.
In image 10 (case from Dr. Gregory Camaleonte) you can appreciate the difference after 1 week with bleaching trays and 10% carbamide peroxide (White Dental Beauty, Optident), used only on the upper arch.
After 1 week with 6% HP (hydrogen peroxide) (WDB White Dental Beauty, Optident) used only on the upper arch.
Tip 4 – Let photography come to your rescue
Need accuracy of color? We don’t always obtain consistent pictures for some difference in some of the parameters, for example flash position. To evaluate results in bleaching cases we need consistent pictures. We need it for the initial and final pictures:
1.To use the same camera
2. Same flash power
3. Same flash position
4. Same magnification ratio
5. Same exposition
6. Same ISO Protocol
1 – When using DSLR camera to document bleaching, there are some variables to take into account: aperture, focal distance, flash power, ISO, speed, flash position, flash power, exposition. You cannot change any of these parameters, and it is better if you have a precise protocol that you use all the time and that you can write down into you patient record because, for example, I usually use camera brackets with point flashes R1C1 and the position of my flashes can vary some degrees very easily, and alter our color accuracy which makes it difficult to evaluate results.
Before and after bleaching pictures. Images took with a DSLR camera. Nikon 7200 with Nikkor 105mm micro lens f22 EV+/- 0, 1/125, iso 100, 1,8:1, point flash R1C1 45 degrees, manual flash 1/2 power, shadeguide: Vita Classical+ Bleach colors. It is important to use the same settings for the initial and the final picture to be able to compare color. How we do the picture and what do we need? We need black Flexipalettes, retractors and the most similar sample from the shadeguide. With one hand we hold the camera and with the other the tab. Assistant shows the patient how to hold the retractors and blow air to remove saliva and with the other hand holds the black background as far as possible from the teeth to obtain a pure black.
We should always use the same settings with the DSRL which are the following:
1. The same camera (I use Nikon 7200 with a macro Nikor 105mm)
2. Same flash power (with a Nikon point flash R1C1 power 1/2 and full power with a polarized filter)
3. Same flash position (45 degrees with my point flashes R1C1)
4. Same magnification ratio (1,8:1)
5. Same exposition (f22, +/- 0) 6. Same ISO (100)
Protocol 2: Simplified protocol with Smile Lite MDP (Mobile Dental Photography): a device that allows you to adapt your smartphone to a light system equipped with three groups of LEDs (light emitting diodes). The pictures from your camera will drastically improve. The parameters to set in this case would be the flash power (4 different steps of power) and camera zoom. It allows you to have consistent pictures in a much easier way. It gives you the possibility to take pictures with a polarizing filter which is ideal in color comparison. Even though it is not scientifical ,the preprocessing and the postprocessing of the images in the phone sensor are amazingly precise. They give an outstanding exposure and white balance. We strongly suggest this tool to three kind of people: first, to people who lack knowledge in photography and are not interested in learning, then to those who rely on the assistant or hygienist to document, and those who are not willing to spend or can not afford an expensive DSRL camera and lenses.
Pictures taken with Smile Lite MDP. Flash power:2 Without Polirizing filter
We recommend the following type of photography to document bleaching:
– Polarized: the ideal because it eliminates all the reflexes and let us appreciate color.
– Twin Flash 45 0 45: a good picture because it creates reflects only in transitional angles.
– Ring flash: not ideal because it gives a lot of glare in the buccal surface.
– Diffusors: not ideal because reflections are too white and kill the color.
– Studio portrait: the least ideal to appreciate color differences.
Accessories to document: to document bleaching we need good cheek retractors, the chosen shadeguide, black photography contrastor, gray contrastor, a good light temperature and a camera. We use Flexipalettes as black contrastors for intra oral photography and gray Flexipalette for color match.
Smile Lite allows us to choose the right color of our shadeguide thanks to the ideal lighting conditions (5500K).
To choose the right color tab we usually use Smile Lite with gray flexipalette for shade matching in the best conditions. 5500K light is the ideal color temperature with neutral gray.
Taking and documenting color is strongly suggested especially to better comunicate with your patient. With this article I want to summarize the tips that I have learnt with experience, the tips that helped me to be consistent and efficient when taking and documenting bleaching cases. Remember to take color before teeth dehydration, an important thing also in conservative and prosthetic dentistry. I would strongly suggest to use a shadeguide specially designed for bleaching because it has more tabs (bleaching tabs) not existent in “normal” shadeguides and besides it is classified by value, the color dimension that changes with bleaching (3D Master Bleachguide, Vita) and not by hue as the other shadeguides. We prefer to bleach the upper arch first with an “at home” bleaching with the bleaching trays because in this way, when he/she see the difference the patient is highly motivated. If you need a simple protocol to document bleaching use the Smile Lite MDP with your telephone in order to have few parameters to take into account before shooting. If you like photography and you already use a DSRL camera you should only be consistent with camera and flash settings to compare color in bleaching pictures.