One of the challenges of practice is working with patients who have a high caries rate. It can be frustrating for both the patient and us as we add new things to their home care regimen in hopes that at their next recall visit we will not be recommending additional treatment. I have a variety of patients in my practice that are high risk for caries including adolescents, elderly patients, and patients with reduced salivary flow caused by a variety of reasons. My first line of defense has been to work with patients to improve their ability to remove the bacteria. Brushing, flossing, and interproximal cleaning devices are a common conversation. Next in line is to add non-mechanical aids, these include prescription strength toothpastes, fluoride varnish and rinses. Sometimes all of these things don’t add up to a real solution, and often patients don’t implement everything we discuss.
One adjunct to caries control that patients seem to easily implement is whitening their teeth with custom trays and Carbamide Peroxide. There is good research that carbamide peroxide is an effective adjunct for caries control. The process works through several mechanisms. One of the primary changes int he oral environment is the elevation of the salivary ph. This occurs quickly, within five minutes of having the tray in, and stays elevated the entire time the trays are in. Carbamide Peroxide has also been shown to kill one of the two bacteria that cause caries. Lastly, one of the main issues in this group of patients can be plaque removal, and the whitening process effectively removes the salivary film and plaque layer off of the teeth.
When being used as an adjunct to caries control one of the things that we do in our office is to make sure that the custom tray extends 1-2mm beyond the gingival crest at the neck of each tooth. This extension acts to seal the tray and keep the gel from leaking out of the tray, as well as making sure that the carbamide peroxide is in contact with the sulcular fluid. Due to this tray extension onto the tissue and wanting to avoid ginigval irritation, we recommend a low percentage of active ingredient. The research that supports Carbamide Peroxide as an adjunct to home care was done with 10% active ingredient. The whitening effects at low doses will also be moderated over a longer period of time.
Terrific article Dr. Brady. This would benefit high caries-risk individuals such as seniors with compromised saliva production. The whitening trays can also serve as fluoride trays to further protect against dental caries.
Lee excellent article. I always enjoy your short insightful thoughts. :) Do you have the reference for the research on this? Thanks, keep up the great work.
There are numerous articles you can look at. Here are a few and you can look at the reference list at the end for more information.
http://jada.ada.org/content/141/6/639.abstract
http://www.dentaleconomics.com/index/display/article-display/372598/articles/dental-economics/volume-100/issue-1/features/bleaching-and-caries-control-in-the-elderly.html
Lee
Hi LeeAnn,what type of wearing regimen do you recommend for your patients with the carbamide peroxide trays?Thanks Jim
I ask them to wear the tray for a minimum of one hour at a time, and the number of times per week can vary. If they are also actively trying to bleach they can use them every night. Otherwise I have them do it more sporadically, suggesting even once a week as a protocol.
Thank you Lee! I have a teenage male patient who has had continued caries control challenges. On his last recare visit, I could feel his disappointment when I told him he needed to return for some restorations, and can’t remember the last time he had an exam and didn’t have any treatment needs. We’re using the prescription fluoride toothpaste which has helped, but hasn’t totally eliminated the problems. It was obvious that this was having a psychological effect on him at a vulnerable time in his social development. I can’t tell you how excited he was when I had my team call him and ask him to come to the office for impressions for bleaching trays. I explained to him why I recommended them, and talked about the “bonus” of whiter teeth. When I spoke to his mother, she actually cried, noting that she’s felt bad for him since he was a child because he always has problems with his teeth and has siblings with minimal dental needs. By the way, I didn’t charge him anything for the trays and the first package of gel. The smile I got from him knowing he had someone on his side was worth much more than the trays we made. These are the moments that make me love what I do. Thanks again!
This is the best!!! Thanks for making me smile and cry today, how much you care is the best gift to your patients!!!
Hi Dr. Brady, I recently attended you lecture in St. John’s Newfoundland, Canada. I enjoyed every aspect of your lecture. This topic interested me and I am going to try with a specific patient in mind. I am wondering if you have patient feedback re:sensitivity with the 10% CP? The patient has very sensitive teeth for which she uses combos of fluoride, rinses, etc.
Can you comment on your patient feedback re: sensitivity. Thanks so much!
Jillian,
The protocol is to use the 10% carbamide peroxide for 15-30 minutes once every 7-14 days. i have never had a patient report sensitivity using this protocol. You could have the patient start using potassium nitrate relief gel int he trays every day for 2-4 weeks before the carbamide peroxide regime, or even switching to a toothpaste that contains potassium nitrate, I find its the best solution to sensitivity from open dentinal tubules on exposed roots.
Lee
Hi,
I enjoy reading your thread with great interest.
Yesterday, one of my RDHs told one pt who has some incipient caries that if you bleach your teeth with trays, your cavities can get bigger. She told me that she learned that from hygiene school. I am pretty puzzled and dumbfounded by it. If it is anything, whitening causes post op sensitivity. It’s a know fact. But to cause more caries? Shouldn’t it be the opposite? I believe carbamide perioxide actually kills of the the bacteria, namely, Lactobaccillus, that cause decay. And hydrogen peroxide that uses in PerioProtect is an oral antiseptic agent in and of itself. Please enlighten.
All of the research and evidence supports that the use of carbamide peroxide reduces the quantity of S Mutans and other bacteria int he mouth by effectively getting rid of the pellicle and biofilm on the surfaces where it contacts. This will reduce a persons caries risk, not increase it. I do not hesitate to have patients begin trays and 10% carbamide peroxide while we are treating any active decay. I am also not worried about increased sensitivity unless the person has advanced, extensive caries with pulpitis issues. Here are some links of other sources for this information that you can share with your hygienist.
http://www.drbicuspid.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=304919
http://www.dentaleconomics.com/articles/print/volume-100/issue-1/features/bleaching-and-caries-control-in-the-elderly.html
http://www.ncbi.nlm.nih.gov/pubmed/20516093
We are implementing this in our office now and I’m curious from a front desk standpoint what codes you are using? I am sure insurance won’t cover this, right? Thanks!
We have just created a code, you are correct no insurance coverage.