Case Example
Your new patient, Mr. Jim Logan, is a 48-year old marketing executive. His chief complaint is the discoloration of his front teeth, which he feels is getting worse as he gets older. He would like them to be as white as they were when he was 25, and even brought in a picture to show you. He would like them whitened within three weeks before he attends his 30-year high school reunion. When reviewing his health history and behaviors, you learn that Mr. Logan is a coffee drinker and former smoker. Upon examination you determine his only treatment needs are preventive care and suggest that you re-evaluate the discoloration after the appointment since the stain could be due to both intrinsic and extrinsic factors. If additional treatment is needed, you can provide vital bleaching in the office or make him custom trays for use with an at-home whitening/bleaching system.
You present the bleaching procedure options and related fees to Jim. He questions you about the differences between them and the new whitening strips that don’t require a tray and can be purchased at the local grocery store. Jim insists the whitening strips are just as effective and cost considerably less.
You are not familiar with the scientific literature on the whitening strips to answer Mr. Logan’s questions thoroughly. You tell him you know the bleaching procedures you have suggested are safe, effective, and produce the desired outcomes in a relatively short period of time. However, you tell him you will be glad to investigate the whitening strips option so each of you are fully informed about the pros and cons of each method before selecting a treatment. With the popularity of these treatment options and new products introduced quite frequently, this information will be a valuable addition to the evidence-based “library” you are creating in your office.
In Evidence-Based Decision Making in Action: Part 1- Finding the Best Clinical Evidence (http://www.thejcdp.com/issue011/index.htm), a search was conducted to identify articles to answer Mr. Logan’s question. By using the PubMed ‘Limit’ features to find the highest level of evidence, several articles were identified. (Figure 1) However, for practical purposes, this article only will appraise one of those studies, A Randomized Clinical Trial Comparing a Novel 5.3% Hydrogen Peroxide Whitening Strip to 10%, 15%, and 20% Carbamide Peroxide Tray-Based Bleaching Systems, by Gerlach, Gibb, and Sagel.12
In selecting this article, you notice the publishing company says it is a peer-reviewed journal, however, no editorial review board is listed. This particular publication is a supplement that focuses on continuing dental education and states those universities who are awarding the credit have representatives that have reviewed the articles for acceptance. Also, it is clear this research study was funded and conducted by Procter & Gamble, the company that manufactures the whitening strips being tested, and the company is the sponsor of this particular issue of the journal. Despite these questionable factors, this article may directly answer Mr. Logan’s question since it is the only published research you found that tests the product on an adult population and directly compares the whitening strip effectiveness with tray-bleaching systems. You recognize this is a new product on the market and the research is limited to that funded by the manufacturer. For these reasons, you decide to continue to analyze the article.
To be sure your analysis
is thorough, you use a Critical Appraisal Form from an article on Therapy adapted
from the Users’ Guides to the Medical Literature as a guide in
your evaluation. Table
1 is a summary of our evaluation and demonstrates the use of this form.
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| Citation Number: Vol. 4, No. 1, Page 045 |
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