A number of our patients have asked us about so-called cosmetic tooth whitening treatments on offer at various establishments such as spas, beauticians, hairdressers or cruise ships. Questions we receive cover areas of legality, effectiveness and safety. This article has been written for informational purposes regarding tooth whitening treatments which are not provided by a registered dentist.
In the first instance, the Law restricts the practice of dentistry to qualified and registered practitioners only. A dentist must be qualified from a recognised University and registered with the Malta Medical Council in order to practice. In the UK and may other European countries it has been unequivocally shown that professional application of materials to the teeth with the intention of whitening them constitutes the practice of dentistry and only a dentist is allowed to perform such treatments. Even if the product can be legally sold over the counter for self-application this does not permit it to be used in a professional context. Several beauty shops and tooth whitening parlours have been successfully prosecuted in the UK as illegally practicing dentistry. As far as we know the definition of what constitutes dental treatment has not been tested in this way in Malta, so far. Of course the moment an additional service such as cleaning the teeth before whitening is added on, then the treatment is clearly the practice of dentistry and non-dentists should be exposed to prosectution for the illegal practice of dentistry.
Safety is an area of high concern when non-trained personell deliver treatment in the mouth. Lets start with the examination. When examining the mouth of someone who came asking for their teeth to be whitened, the dentist will look for tooth decay, cracks, gum disease, mouth cancer and other problems before picking up the colour chart to see how darkly stained the teeth are. Using whitening products in situations where there is a pre-existing problem like a crack in a tooth could aggravate the problem and cause pain, infection or other complications. It should be clear that the level of knowledge of a non-dentist is not appropriate for examining someone’s mouth to say its safe for them to have teeth whitening treatments. Worse, they could miss an opportunity to diagnose something life threatening like mouth cancer.
Next, lets look at products. The mainstay of teeth whitening treatments rely on hydrogen peroxide to whiten the teeth. The European Union (Directive 2011/84/EU) does not allow the sale of teeth whitening products containing more than 0.1% hydrogen peroxide to non-dentists. This directive was issued after careful consideration of what products are safe for over-the counter sale and use. High concentrations of peroxide can be harmful to the gum tissue causing chemical burns and therefore their use must be carefully controlled to avoid gum contact. In spite of this law, many salon-type whitening treatments carried out in the UK have been found to be using high levels of hydrogen peroxide, some up to 23%. Several companies providing tooth whitening products to salons have tried to circumvent this law by using chlorine dioxide as a teeth whitener. This has been shown to be dangerous in several ways, including erosion of teeth, permanent sensitivity, loss of lustre and increase in discolouration, the details of which which are beyond the scope of this article. More recently sodium perborate (which breaks down to release hydrogen peroxide) and other members of the borate family are being found in the ingredients of non-dentist teeth whitening products. A recent press release from the Council of European Dentists states that borates have been classified as carcinogenic, mutagenic, or toxic for reproduction (CMR) and as such have been banned from cosmetic products. This is of concern as we have noted brands present in Malta which list sodium perborate on the list of ingredients.
The next concern regards cross infection control and other hygiene considerations. Dental clinics are regulated, inspected regularly and are required to show proof of sterilization cycles and maintenance of sterilization equipment. None of these safety guards are in place within the salon and therefore the level of instrument and equipment sterilization is up to the discretion of the owners.
The last concern regards responsibility. Dentists are professionals who have legal resposibility for their work and who are required to have indemnity arragements. The liability of salons or beauty parlours is neither as clearly defined nor are they obliged to have indemnity cover. If something goes wrong, who is responsible?
We are concerned that establishments promise a given number of shades whiter using what they insist is legally an over the counter product containing low levels of whitening agent. Even with access to professional-grade materials containing up to 6% hydrogen peroxide, lasers, ultrasonic tooth scalers and abraisive polishing pastes, dentists sometimes struggle to achieve the desired levels of tooth whitening which are asked of them. In addition the act of keeping the mouth open for some time will cause the teeth to dry out, and will dehydrate the enamel making teeth look whiter than they really are (think of a wet sugar cube and a dry one – the dry one reflects white light more than the wet one). There is therefore an immediate whitening result which is purely temporary caused by the teeth drying out! This can make it easy to claim a result even though it is short lived. What matters to our patients however, is the permanent result.
Tooth whitening by salons, beauticians or other similar establishments may constitute the illegal practice of dentistry. They appear to make claims for efficacy which would be hard to achieve without professional-grade materials and historically and presently use substances which may be dangerous. The advice we give to people calling to enquire about such treatments is that tooth whitening should only be performed under the supervision of and after a detailed dental examination by a qualified dentist. If you would like to read more visit www.safetoothwhitening.com
Malta Medical Council Registers: https://health.gov.mt/en/regcounc/medicalcouncil/Pages/Registers.aspx
General Dental Council UK Illegal Practice Prosecutions: https://www.gdc-uk.org/Membersofpublic/Illegalpractice/Pages/Illegal-practice-prosecutions.aspx
European Council Directive 2011/84/EU: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:283:0036:0038:en:PDF
British Dental Journal – Borates Banned in EU: http://www.nature.com/articles/bdjteam201575
Council of European Dentists Press Release: http://www.eudental.eu/component/attachments/attachments.html?id=1923
Linda Greenwall – The dangers of chlorine dioxide tooth bleaching. Aesthetic Dentistry Today July 2008 Vol 2 No 4: http://www.academia.edu/5820972/The_dangers_of_chlorine_dioxide_tooth_bleaching
Y. Li and L. Greenwall – Safety issues of tooth whitening using peroxide based materials. British Dental Journal 215 (July 2013) p29-34 https://www.dentalhealth.org/uploads/download/resourcefiles/download_187_1_Li%20and%20Greenwall%20Safety.pdf
Daily Mirror (UK) articles