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Pediatric and Adolescent Tooth Whitening
(Additon to Tooth bleaching)

Pediatric and adolescent tooth whitening is the practice of dental bleaching in patients whose mouths have not fully matured. The permanent dentition is realized between the ages of 17 and 21 years. The majority of testing to determine the safety and effectiveness of tooth whitening has been performed on adults. Whitening that is practiced on children and adolescents commonly uses trays with low concentrations of hydrogen peroxide or carbamide peroxide and is under the supervision of a dentist. The extent of possible toxicity and adverse results increases with the overuse of whitening products.

In the field of cosmetic dentistry, dental bleaching is the most requested procedure among patients between the ages of 20 and 50 years. Whitening is a $600 million industry and it increases up to 20 percent every year. It is becoming a more common procedure among pediatric and adolescent patients. The purpose of whitening treatments is to provide the patients with a healthy, functional, and attractive dentition; brightening dark or discolored teeth. Tooth whitening and micro-abrasion, are conservative treatment options for discolored teeth compared to composite veneers. A consultation with a dentist before beginning a whitening treatment can determine whether the patient is of an appropriate age to begin tooth whitening, and also determine what whitening methods are appropriate. A dentist can conclude whether tooth whitening will cause increased sensitivity or permanent damage in the oral cavity.

Tooth Discoloration in Children and Teenagers
Younger patients experience discoloration from a number of sources. A diet high in sugars, which is typical of children, can produce cavities and discoloration. Consuming pigment-producing drinks like sports drinks, coffee, and tea, and smoking cigarettes can result in stains. According to the Center for Disease Control and Prevention, 1 in 5 teenagers in the United States smoke cigarettes. Bulimia will cause tooth discoloration and cause the enamel to erode. Minocycline is an antibiotic used for acne treatment in teenagers and can cause teenagers teeth to turn from white to gray in as little as two years. Other sources include orthodontic treatments, tetracycline exposure, fluorosis, generalized yellowing, trauma to deciduous teeth, and infections around a deciduous tooth.

Adolescent Tooth Development
Dental bleaching is typically not performed until the patient is 14 years of age or older. A patient may remain in mixed dentition, the developmental stage in children when they have both deciduous and permanent teeth, until the age of 14. Primary and permanent teeth have a diversity in the thickness of enamel, which causes significantly varied tooth coloration during the mixed dentition. If whitening is practiced before teeth are fully erupted, it will only brighten the exposed enamel. Bleaching during this developmental period would cause dissimilar dental appearance once the patient reaches permanent dentition. Between the ages of 12 and 14 the soft tissue surrounding teeth is in excess and has not fully developed yet, so the tissue can be burned when using a gel tray. At age 14 the pulp of each tooth is formed completely and the patient will be subject to less tooth sensitivity. At age 17 the enamel has fully calcified and will be less susceptible to harm from whitening. Many over-the-counter treatments like whitening strips, pens, gels with mouth guards advise against use under the age of 12 in their disclaimers. Children under the age of 12 can safely use whitening toothpastes, mouth rinses, flosses, and whitening gums. In-office bleaching, which uses light systems, is limited to patients 18 years and older because of the possibility of pulp damage.

Positive Effects
Dental bleaching brightens teeth through the use of carbamide and hydrogen peroxide. Increasing the concentration of these bleaching agents will raise the level of color improvement. There is an exponential relationship between the concentration of hydrogen peroxide and the number of applications necessary for the best shade result. Oral hygiene among teenagers is improving as a result of having an aesthetic smile.

Adverse Effects
Whitening can decrease the bond strength in resin-based restorative materials. Children and adolescents are especially at risk for developing tooth decay, since they tend to have a diet high in sugar and some are less diligent with hygiene habits such as brushing, flossing, and rinsing with fluoride. Dental restorative materials have a life span of about 8 to 13 years. This lifespan is decreased with the use of whitening agents.

The chance for damage to nerves and to the enamel increases as more whitening products and higher concentrations are used. Slight trauma that is caused by bleaching solution or the heat of the light used during in-office bleaching procedures can cause major sensitivity to the nerves or possibly nerve damage. Nerves are more susceptible to damage until the age of 17. Nerves are larger while teeth develop. As a child grows, the nerves shrink about 50% between the ages of 12 and 17.

Common complaints during whitening trials include minor oral irritation and tooth sensitivity. Tooth sensitivity is more common than oral irritation. Sensitivity during or after a bleaching treatment affects 8% to 66% of patients. Tooth sensitivity and gum irritation are more traumatic experiences for children than adults.

Possible Treatments of Adverse Effects
The side effects of tooth sensitivity and oral irritation can be treated both actively and passively. There are several options to passively treat tooth sensitivity from in-office or at-home treatments. The frequency or duration of the treatment can be decreased or stopped. The concentration of carbamide peroxide or hydrogen peroxide can be decreased. An active at-home treatment involve the use of fluoride rinse or a desensitizing toothpaste. The International Association for Dental Research experimented with fluoride and potassium nitrate to eliminate sensitivity. The fluoride obstructs holes and tubes, which slows down the fluid flow that causes sensitivity. The potassium nitrate, like hydrogen peroxide, pierces through the enamel and dentin, and reaches the pulp. Potassium nitrate acts as a painkiller or anesthetic. It prevents the nerve from repolarizing following the depolarization in the pain cycle.