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The emphasis here must be on the word "complete". Even though tooth whitening is inherently a cosmetic procedure, the dentist is as fully responsible for the wellness of the patient as with any other dental treatment. The standard medical questionnaire used by most dental offices should suffice, however, some additional questions relating to materials and habits that have a direct effect on tooth coloration may need to be added to the basic list.

Pregnancy. While there has been no indication that tooth whitening during pregnancy is contraindicated, conventional wisdom leads one to avoid any elective procedure until its absolute safety under these circumstances is documented.

Fig. 4-1

Tetracycline exposure. It will be helpful for the dentist to know whether tetracycline has had any part in the discoloration of the teeth. This knowledge may change both the approach to, and prognosis of, treatment.

It is well established that the ingestion of tetracyclines at times of amelogenesis and dentinogenesis will affect the coloration of the teeth being formed at that particular time. The antibiotic, taken by an expectant mother in the latter half of pregnancy will result in the staining of the deciduous teeth and the incisal regions of the permanent anteriors. Any child who is given tetracycline during the years of tooth formation will develop stained permanent dentition.

Fluoridation. In certain parts of the world, the drinking water fluoride concentration exceeds lppm. Where the natural concentration exceeds 4ppm, most of the children are likely to develop significant discolorations.

In much of North America, the drinking water is fluoridated, and if not, children are generally given a fluoride supplement. This has brought abouL an improvement in children's dental health, but has also been the cause of increased minor fluorosis. Since the fluoride additives taste good, children might sneak an extra tablet or two. They may also regularly swallow the pleasant tasting fluoride toothpastes that are on the market today. In either case, a chronic small excess of fluoride can create chalky areas on the developing tooth which will be noticed upon eruption.

Trauma. The discoloration induced by traumatic injury is often limited to a single tooth. Even more of a problem is the tendency of traumatized teeth to continue becoming darker (or yellower) long after they have sustained an injury, despite the dentist's best efforts to stabilize and blend the coloration with the rest of the dentition.

Habits. Certain forms of repetitive behavior may influence the present coloration of the teeth, and the likelihood that an improved appearance can be maintained. The dentist must know if the patient is an active drinker of tea, coffee, or colas. These beverages cause a readily correctable form of staining, but they may compromise the maintenance of a whitened smile. Smoking (cigarettes, pipes) and chewing tobacco are much more invasive. The stains follow the microfissures of the tooth structure internally, and may be very difficult to eliminate.

Sensitivity. Any known sensitivity to hydrogen peroxide, polyresin, acrylic, or any of the other materials used for tooth whitening will certainly alter the course of treatment.

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