Position Summary
On the grounds of public safety, only registered dental practitioners who are educated, trained and competent in teeth whitening (bleaching) procedures should use or supply teeth bleaching products containing more than 3% hydrogen peroxide or equivalent.
1. Background
1.1. Use of teeth whitening formulations manufactured for professional use to bleach the teeth of patients has become a common part of dental practise, sometimes with the aid of a light or heat source that may shorten the application time required. Suitably trained dental practitioners may also supply suitable patients with professional teeth whitening products and custom-fitted trays for selfadministered home-use under their guidance.
1.2. Hydrogen peroxide is the active bleaching agent in most products used by dental practitioners to bleach vital teeth. The effective concentration of hydrogen peroxide varies greatly from concentrations as low as 3-6% for some products supplied to patients for home-use to 35% in some office-based bleaching products. Many bleaching products contain carbamide (urea) peroxide, onethird of its concentration being equivalent to hydrogen peroxide, e.g., 18% carbamide peroxide approximates 6% hydrogen peroxide. While weak solutions (<3%) of hydrogen peroxide have been
used in the oral cavity in the form of mouthwashes and toothpaste for many years with few problems, the potential for adverse effects on the oral tissues is increased when higher concentrations are used.
1.3. WorkSafe Australia’s current guidelines designate hydrogen peroxide at concentrations above 5% as a hazardous substance. Direct exposure of the skin, eyes and mucous membranes to hydrogen peroxide may cause severe irritation or burns, while ingestion may cause irritation to the oesophagus and stomach resulting in bleeding or sudden distension. Percolation of hydrogen peroxide into the pulpal tissues - often accelerated by exposed dentine and enamel fractures - can lead to pulpal
inflammation. For this reason, it is necessary to take great care when handling and using hydrogen peroxide bleaching agents, especially the higher concentrations.
1.4. The incorrect application of heat and other forms of energy during teeth whitening procedures, such as light from a plasma arc lamp or high-power (Class 4) laser may cause pulpal damage to the tooth and burns to adjacent soft tissues, and failure to ensure use of the appropriate protective eyewear may also cause irreversible injury. AS/NZS 4173:2018, Safe use of lasers and intense light sources in health care specifies requirements for dental practices and the cosmetics industry, including required standards of training.
1.5. All registered dental practitioners with appropriate levels of training and competence are permitted to undertake dental procedures using Class 4 lasers, but Western Australian, Queensland, Victorian, and Tasmania legislation requires that practitioners in these states first obtain a licence to do so from the appropriate state regulatory authority.
1.6. The Poison Standard sets out restrictions on the availability of teeth whitening products containing various concentrations of bleaching agents, and these restrictions are enshrined in all state and territory poisons legislation. The Poisons Standard recognises hydrogen peroxide 3-6% and carbamide peroxide 9-18% as Schedule 5 substances requiring “Caution”, meaning that teeth whitening products containing up to these concentrations can be sold direct to consumers if they are labelled with stipulated safety warnings.
1.7. Schedule 10 of the Poisons Standard lists substances of such danger to health as to warrant prohibition of their sale, supply and use other than in specified exempt circumstances. Schedule 10 specifically states that teeth whitening products containing more than 6% hydrogen peroxide or 18% carbamide peroxide may only be sold, supplied and used by registered dental practitioners as part of their dental practice. These provisions are formalised in all state and territory poisons legislation.
1.8. In August 2021, the Board published “Guidance for registered dental practitioners: Using and supplying teeth whitening products” which cites the Poisons Standard, Therapeutic Goods Administration (TGA) advertising requirements, and Australian Consumer Law, stating that “You can only use teeth whitening products in line with your training and the law”.
1.9. Peer reviewed studies indicate that peroxide-containing teeth bleaching products are safe and effective when used by or under the supervision of a dentist and according to the professional directions for use. The most common side-effects are transient tooth sensitivity and soft tissue irritation during or immediately following treatment.1
1.10. An increasing variety of teeth whitening products are available for direct sale to Australian consumers over-the-counter (OTC) and online. From time to time, some products containing concentrations of bleaching agents that exceed legal limits in Australia have been found to be available online to Australian consumers.
1.11. The marketing of some teeth whitening products directly available to Australian consumers encourages unrealistic expectations about whitening results and promotes regular ongoing use to maintain desired effects. This is a concern given the lack of clinical data supporting frequent home use of such products over long periods.2
1.12. Teeth whitening services are now also increasingly offered by unregulated, unqualified non-dental practitioners in settings such as beauty and hair salons, shopping mall kiosks, dedicated teeth whitening salons, or via mobile services that travel to a location convenient to the consumer.
1.13. Many non-dental practitioner teeth whitening services claim that their practitioners are “teeth whitening specialists” who have the knowledge or training to perform teeth whitening procedures safely. However, only registered dental practitioners have the expertise to assess whether bleaching is safe for individual patients, to recommend the most appropriate technique and materials, and to provide treatment that meets regulated safety and quality standards of care.
1.14. Dental practitioner advertising should be compliant with the relevant Australian Consumer Law and TGA requirements.
Definitions
1.15. BOARD is the Dental Board of Australia.
1.16. DENTAL PRACTITIONER is a person registered by the Australian Health Practitioner Regulation Agency via the Board to provide dental care.
1.17. NATIONAL LAW is the Health Practitioner Regulation National Law Acts 2009 as in force in each state and territory.
1.18. TOOTH WHITENING is the use of teeth whitening products designed to penetrate the teeth and bleach intrinsic and/or extrinsic tooth discolourations, as opposed to products such as whitening toothpastes that are intended to remove surface staining.
2. Position
2.1. Only dental practitioners who have been educated, trained, and attained competence in teeth whitening can assess whether it is safe for individual patients to undergo teeth whitening, and to diagnose and treat any dental or oral health problems that need to be addressed first to minimise any potential discomfort or health risks associated with exposure to bleaching agents.
2.2. Only dentists should be able to supply patients with teeth whitening (bleaching) products incorporating hydrogen peroxide at concentrations exceeding 6% or carbamide peroxide exceeding 18%.
2.3. Teeth whitening should only be performed if the treatment can be justified, and after a comprehensive dental examination has been conducted by a dentist.
2.4. Risks and costs associated with the treatment should be explained to the patient and documented along with informed consent. Practitioners should ensure that patients have realistic and reasonable expectations regarding the results of the bleaching treatment.
2.5. Regulatory authorities must take appropriate action to educate the public about the risks of tooth whitening procedures undertaken by persons other than dental practitioners and encourage them to report any concerns they have about teeth whitening products or services to the appropriate authorities.
2.6. The Australian Competition and Consumer Commission (ACCC) should continually monitor the advertising and supply of teeth whitening products and services to assess and enforce compliance with relevant legislation, including state and territory poisons laws, mandatory labelling standards for cosmetics, and provisions of the Competition and Consumer Act 2010 relating to product safety, product liability, product advertising, and mandatory reporting of adverse events causing consumer harm.
1. lkahtani R, Stone S, German M, Waterhouse P. A review on dental whitening. J Dent 2020;100:103423; Epple M, Meyer F, Enax J. A Critical Review of
Modern Concepts for Teeth Whitening. Dent J (Basel) 2019;7:79.
2 Eachempati P, Kumbargere Nagraj S, Kiran Kumar Krishanappa S, Gupta P, Yaylali IE. Home‐based chemically‐induced whitening (bleaching) of teeth in
adults. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD006202. DOI: 10.1002/14651858.CD006202.pub2
