White fight

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“The effect (of teeth whitening) on individuals can vary greatly and it’s difficult to assess its effect, making it all the more important that consumers are first seen by a dentist before they use the kits at home,” says Prof Ian Meyers
“The effect (of teeth whitening) on individuals can vary greatly and it’s difficult to assess its effect, making it all the more important that consumers are first seen by a dentist before they use the kits at home,” says Prof Ian Meyers

The debate over what is a safe level of peroxide in at-home tooth whitening kits continues, with battle lines drawn between the profession and the industry. A.M. Walsh reports.

In the middle ages, dentists and barbers were one profession, dedicated to the improvement of personal appearance. Customers could get a shave, then their teeth whitened by being filed with a metal apparatus and then doused with nitric acid. As the current debate over teeth whitening shows, the definition of what is cosmetic and what is therapeutic medicine—and how far a person will go to improve their smile—is still as current as ever.

In May last year, following complaints of injuries by consumers, the Australian Competition and Consumer Commission (ACCC) investigated the safety requirements for teeth whitening products. They then ruled that any products that contained six per cent or more of hydrogen peroxide and 18 per cent or more of carbamide peroxide be removed from the shelves. Whitening kits with these levels are now only available to dentists for use in clinics.

The major stakeholders in this debate are dental professionals and the suppliers of dental products. While all agree with the ruling regarding kits that contain more than the six per cent/18 per cent levels of the chemicals, there is a fundamental disagreement about what constitutes acceptable over-the-counter product.

The Australian Dentists Association (ADA), representing the dental profession, current listings of the chemicals don’t go far enough, prompting them to lobby for a change to the Uniform Scheduling of Medicines and Poisons (SUSMP). The primary concern of the ADA’s submission was to procure a scheduling outcome “that protects the public from injury associated with inappropriate use of some teeth whiteners.” They proposed that teeth whitening products containing above three per cent hydrogen peroxide and nine per cent carbamide peroxide be included in Schedule 4 of the Therapeutic Goods Act, defining them as ‘medicines’ and not ‘cosmetics’, and that whitening kits containing these levels be accessible to consumers for at-home use only after receiving a dentist’s approval. This would restrict over-the-counter sales of more whitening kits.

“By virtue of Dental Board of Australia (DBA) regulation, the provision and use of teeth whitening products by untrained personnel upon third parties falls within ‘the practice of dentistry’.”

The crux of ADA’s argument is, because of the inherent risks associated with using hydrogen and carbamide peroxides on the soft tissue of the mouth and throat, whitening teeth is something best performed under the supervision of a dentist. The ADA considers teeth whitening, using higher concentrations of chemicals that cause irreversible outcomes, to be dentistry. In their submission, the ADA quoted: “By virtue of Dental Board of Australia (DBA) regulation, the provision and use of teeth whitening products by untrained personnel upon third parties falls within ‘the practice of dentistry’.” The submission also states there’s danger in over-using the chemicals, which can make teeth brittle, translucent and sensitive, with “many consumers bleaching their teeth into oblivion”.

Higher levels of peroxide may increase tooth sensitivity, but it’s also proven that more concentrated peroxide gives faster results.
Higher levels of peroxide may increase tooth sensitivity, but it’s also proven that more concentrated peroxide gives faster results.

Professor Ian Meyers, vice chairman of the ADA’s Dental Instruments, Materials and Equipment Committee, stresses that the submission is all about public safety. “Research shows that higher amounts of peroxide are dangerous and can cause injury,” he says. “The public need to be aware of the risks involved and the best way to do that is to be under the guidance of a professional.

‘These are dangerous chemicals and not suitable for unsupervised use at home,” continues Prof Meyers. “I want to stress that the ADA is not about protecting services, but entirely concerned with public health safety.”

However, suppliers of dental products are keen to keep the existing listings of hydrogen peroxide and carbamide peroxide based on existing scientific evidence. Troy Williams, CEO of the Australian Dental Industry Association (ADIA), says, “The National Drugs and Poisons Schedule Committee (NDPSC) established and subsequently confirmed the current scheduling classifications. As part of these reviews, the NDPSC comprehensively reviewed the toxicology and safety of hydrogen peroxide. At the end of the day it was a factual determination and there was simply insufficient clinical evidence tendered to support any other outcome.”

Professor Meyers agrees there has been no specific research conducted regarding the lower amounts of hydrogen peroxide and carbamide peroxide in question, but says, “the effect on individuals can vary greatly and it’s difficult to assess its effect, making it all the more important that consumers are first seen by a dentist before they use the kits at home.”

The Advisory Committees on Medicines Scheduling (ACMS) and ACCS, however, did not find this argument compelling enough to warrant changing the listing, deciding instead to add a new Appendix C clarifying the use of levels above six per cent/18 per cent.

Science aside, economics are also central to this issue. Dental suppliers are concerned that over-regulation of teeth whitening would increase the financial burden on domestic suppliers who would then fold. This would in turn lead to an increase in the purchase by consumers of OTC hydrogen peroxide (available in supermarkets at three to six per cent solutions) and internet-supplied products that are beyond the control of regulation, and therefore would put consumers even more at risk.

Higher levels of peroxide may increase tooth sensitivity, but it’s also proven that more concentrated peroxide gives faster results. A quick search on the internet reveals that the banned whitening kits from last year are easily ordered from overseas—in fact, whitening gels containing carbamide peroxide up to 44 per cent are also available. Most dentists use solutions containing between 20-40 per cent of the chemical.

There’s no question that both the ADA and Australian Dental Industry Association (ADIA) are concerned for public safety, but perhaps the debate needs to be shifted from the what and who, to the how. It costs up to $500 to have an in-chair treatment performed by a dentist, a procedure usually completed in about one hour; over-the-counter products cost from as little as $30 for recommended use over a two-to-four week period. If unregulated products offer the efficacy of the first procedure with the cost of the second, it seems this is where the real problem lies regarding dangerous levels of teeth-whitening chemicals.

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