Whitening trays for a patient with sensitivity and existing restorations
A 29-year-old woman requests at-home vital whitening with custom trays. She has mild, reversible cold sensitivity on the upper anteriors, multiple composite veneers on teeth 12 through 22, and a porcelain crown on tooth 11. She drinks two cups of coffee daily and uses an over-the-counter whitening toothpaste. She has no caries, no exposed dentin on exam, and no history of eating disorders. The dentist has approved at-home whitening with a 10% carbamide peroxide gel and asks you to make the trays and give instructions.
1. What should you tell her about expected results on her composite veneers and porcelain crown, and why?
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Explain that whitening agents act on natural tooth structure and generally do not change the color of composite or porcelain restorations. Her natural teeth may lighten while the veneers and crown remain their current shade, which can create a color mismatch. She should understand this before starting, and the dentist should confirm the plan. If the mismatch becomes unacceptable, the restorations may need replacement after whitening, so record the baseline shade and discuss expectations. Do not promise that the restorations will whiten. Also note that margins and any exposed dentin around restorations may be more sensitive.
2. How do you fabricate the trays and instruct her to use the gel given her sensitivity?
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Take accurate alginate impressions of both arches, pour them promptly, and fabricate trays with a reservoir and a scalloped border that ends at or just beyond the gingival margin without extending onto the gingiva. Trim the trays so they do not impinge on the gingiva. For sensitivity, advise using a lower concentration or shorter wear time as directed by the dentist, and consider a desensitizing agent before starting. Instruct her to place a small drop of gel in each tooth area, seat the tray, wipe excess gel from the gingiva, and follow the dentist's prescribed wear time, typically overnight or a specified number of hours for 10% carbamide peroxide. She should not eat or drink while wearing the tray, and she should remove it and rinse afterward.
3. What home-care and follow-up advice should you give, including about her coffee and whitening toothpaste?
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Advise reducing or limiting coffee during the whitening period and rinsing with water after drinking it, since pigments can redeposit. Continue brushing with a soft brush and a fluoride toothpaste; a whitening toothpaste is abrasive and does not change intrinsic color, so it is not a substitute for the tray gel. Avoid highly pigmented foods and drinks and tobacco during treatment. Report sensitivity that persists or worsens, and do not extend wear time beyond instructions. Schedule a follow-up so the dentist can assess shade and sensitivity, and remind her that results vary and may need maintenance. Keep the trays clean and store them as instructed.