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Greenwall-Cohen J, Francois P, Silikas N The safety and efficacy of ‘over the counter’ bleaching products in the UK. Br Dent J. 2019; 226:271-276
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General Dental Council. GDC statement on ‘direct-to-consumer’ orthodontic treatment. 2021. https://tinyurl.com/2p99uf4e (December 2021)
An increase in patient awareness and education has seen the demand for cosmetic dentistry rise. The use of social media applications such as Instagram provide patients with a plethora of information on procedures, such as direct composite bonding, veneers of different types and the align, bleach and bond protocol. When using social media applications, it is common to see advertisements for ‘peroxide-free’ gels, from a range of brands, many of which ‘influencers’ and celebrities are paid to endorse. These direct-to-consumer products allow the patient to bypass the traditional method of speaking to their dental practitioner. This coupled with the reach that some of these companies possess on social media platforms means that patients could be putting their future dental health at risk. This article outlines the risks involved in the use of ‘peroxide-free’ bleaching gels, which are becoming increasingly popular among patients. Furthermore, the article also outlines the potential pitfalls associated when ‘peroxide-free’ gels are used in conjunction with other unregulated dental products such as ‘charcoal toothpastes’ and ‘direct-to-consumer aligners’
CPD/Clinical Relevance: This article aims to help clinicians to recognize and discuss the dangers associated with unregulated whitening products and direct-to-consumer orthodontics with patients.
Article
As a general dentist working in an area with demands for ‘cosmetic dentistry’, many patients request treatment, such as composite bonding, veneers, crowns and most commonly, at-home tooth whitening (bleaching). A detailed discussion with patients is required to ascertain their preferences regarding wearing bleaching trays overnight, or for a 30-minute period during the day, to help the clinician to decide which system to choose.
Procedural overview
At-home bleaching can be a simple and safe procedure, which can benefit a patient aesthetically. The procedure is often straightforward, involving two to three appointments, consisting of the following.
A dental examination
This ensures the patient has good oral health and is suitable for bleaching (eg has no active dental disease, periodontal issues or is pregnant).
Impressions, or an intra-oral scan, must be undertaken in order to construct custom-made bleaching trays.
Recording a pre-operative shade using a VITA shade guide.
Supplementing this record with the use of a digital photograph is key to save contemporaneous records and will help to educate patients in order to manage their expectations.
A discussion to obtain valid consent should happen at this stage.
Fit appointment
The patient's bleaching trays are tried to assess comfort, extensions and fit.
The patient should be shown how to apply the bleaching gel, place/remove their trays, and how to keep their trays clean.
It is imperative to run through common side-effects, in particular how to manage any sensitivity or sore gingival tissues.
The correct amount of hydrogen/carbamide peroxide gel is dispensed.
Review appointment
Within 2–3 weeks the shade is reviewed to assess the outcome.
Post-operative photographs are taken and compared with the pre-operative photographs against a shade tab.
Nightguard vital bleaching (NGVB) with 16% carbamide peroxide1 (or 6% hydrogen peroxide) can provide excellent and reliable results for a patient.2 There has been much research into treatment efficacy, which means that once it has been prescribed by a dentist, vital bleaching is one of the safest and best-tested methods for tooth bleaching.3
Additionally, one should mention in-house bleaching, which can be done within a surgery setting by a dentist or dental care practitioner (DCP), who has had the appropriate training (eg a dental therapist or dental hygieniest).
In this procedure, the bleaching gel is applied to the teeth after protection of the soft tissues through the use of a rubber dam or gingival gels.4 Once applied, the bleaching gel is then slightly agitated and left on the teeth before being removed and replaced at 15-minute intervals over a 1-hour period. A light or heat source may be used in conjunction with this type of treatment. There is no evidence that light is effective in enhancing overall results.5
Although an in-surgery bleaching treatment using 30% hydrogen peroxide can achieve a short-term significant difference in shade after only a single session, many more sessions are needed to achieve an outcome that is similar to that achievable much more safely using at-home bleaching systems.6
In practical terms, in-surgery bleaching is also limited in the UK because clinicians are restricted to a maximum prescription of 6% hydrogen peroxide under European law.
Direct-to-consumer products
It has become increasingly common for patients to forego the abovementioned safe procedures and take control of their own dental treatment.
Although dentists and DCPs are aware of unregulated bleaching procedures and the risks they encompass, it seems there is a lack of understanding and awareness among the public at large.
With social media consumption on the rise, one can view countless adverts for ‘whitening gels’, ‘whitening at-home services’ and most interestingly, ‘peroxide-free whitening’. These websites often have large numbers of followers, who have been directed there by an influencer, YouTube personality or celebrity. Unfortunately, the consumers of these products may well believe that they are gaining a bespoke and safe whitening service when, in fact, this is not true.
Delving deeper into ‘peroxide-free’ products
‘Peroxide-free gels’ usually contain glycerin (which acts as a bulking agent), and sodium bicarbonate and sodium chlorite (both of which are listed as key bleaching ingredients). It is known that sodium bicarbonate (baking soda) has an abrasive nature, especially in its powder form, while sodium chlorite, in the presence of acid, significantly reduces the hardness of the teeth. Analysing these constituents and delving deeper into the relative harm that these ingredients can cause to the teeth is deeply worrying.
Some companies sell their products alongside a small blue LED light, which is either battery powered or plugged into the user's phone via a USB connection, often as a way to emulate a ‘surgery’ experience. Again, there is no scientific evidence whatsoever that the use of blue light accelerates or enhances the overall results of the bleaching treatment.6
Over-the-counter (OTC) products are often a tempting purchase for the buyer; however, it has been found that non-hydrogen peroxide OTC products have the potential to damage enamel and lighten teeth. Furthermore, the lightening effect of the OTC products is highly questionable but is more likely to occur with the use of sodium chlorite-based products.8 It was also noted in one study that in four out of five products, citric acid was listed as the accelerator, which over time both softens and dissolves the enamel as indicated by a significant reduction in microhardness, measured by the Vickers microhardness scale.9
Initially, the consumer may see a very short-term whitening effect. However, over time the enamel can become damaged, exposing the underlying darker dentine, which is irreversible.
While looking at the product pages on these websites, it was noted that the whitening products come in a variety of options that include non-specific, generic gum shields, adhesive strips, or paint-on pens. These are often sold as a package along with charcoal toothpaste, which is marketed as a naturally brightening toothpaste made to enhance the whitening effect of the gels. Discount codes and vouchers are easy to find online or by signing up to a mailing list, and are provided to entice the buyer to spend more, and effectively buy more unproven and dishonest products.
It has been found the use of charcoal toothpaste may result in negative aesthetic effects, possibly necessitating the replacement of restorations with less than ideal adaptation, which acquire grey or black marginal charcoal staining.7
Moreover, their use may present with a potential for increased abrasivity, depending on the nature, method of preparation and particle size distribution of the charcoal included in the formulation. Additionally there may be an association with hypersensitivity, forms of which may prove difficult to resolve with continued use of charcoal toothpastes.
Direct-to-consumer aligners
Interestingly, one website went above and beyond to also offer direct-to-consumer aligners for orthodontic treatment. These required no dental supervision, with no mention of an oral health assessment or investigations beforehand. The patient simply needs to take their own impressions and send them back in the post, or book an appointment to have a scan taken at a high street outlet, to receive their aligners. This inherently increases the risk of misdiagnosis and lack of informed consent in the absence of regular face-to-face consultations as in a dental setting. The General Dental Council, released the following statement in February 2020:10
‘We are continuing to gather evidence about the potential risk of harm to patients from ‘direct-to-consumer orthodontics' and other forms of dental care offered remotely. We have contacted providers of these services to seek clarification on the procedures they follow and how GDC registrants may be involved’9
‘The GDC is aware of an increasing number of organisations offering services remotely, including ‘direct-to-consumer’ orthodontics using clear aligners. These services fall within the legal definition of dentistry so can only be performed by dentists and dental care professionals who are registered with the GDC. All dental professionals must adhere to the GDC's Standards for the Dental Team. Anybody practising dentistry while not registered with the GDC could be subject to prosecution for illegal practice’10
Interestingly, direct-to-consumer providers remain popular, with physical outlets appearing in cities around the country.
The power of social media
Influencers who promote the products on Instagram were contacted directly via the app. Out of the approximately 15 who were messaged, only five replied. After informing them about the harm these products may cause the teeth, along with the dangers involved in promoting these kinds of products to their followers, there were messages of shock and disbelief.
One influencer was honest enough to state that they did not ‘trust the product.’
Most celebrities appear to post on their profile to garner attention from other brands and companies, thereby generating further remuneration, regardless of the consequences for the teeth of their followers.
Summary
In a society where we are hyperaware of what is going into our bodies, it is concerning that it is so easy for companies to offer alleged dental solutions with no evidence-base and no academic or theoretical understanding of what is actually involved.
The direct nature of many of the websites means that, unlike dentist-prescribed bleaching, there are no pre-assessments carried out – meaning that age, medical history, oral hygiene and other important factors are completely disregarded.
The main concern is that certain patients, who may already have a distorted view of societal norms, often due to what they consume on social media and reality television, may purchase these products without realizing how much harm they might cause themselves. It is crucial that dentists are able to recognize and address these potential ‘body-dysmorphic’ ideas when such patients are in the chair.
The author has found a number of his own patients (ranging between the ages of 14 and 17) stating that they have purchased bleaching gels or charcoal-containing toothpastes online or through a social media application, with little idea of what the potential risks may entail.
Overall, it is suggested that there should be more safety regulations around the products that can be sold online by non-medical or dental companies. As dentists, we always wish to ensure our patient's best interests come first, but that does not seem to concern some online companies or influencers.
This worrying online purchasing trend allows consumers to bypass the many safety processes that trained dentists can offer. If we are already at a place where patients can self-diagnose and, in effect, prescribe their own orthodontic treatment plans with no radiographs or assessment of their dentition, one dreads to think about what may come next.
