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Dental Bleaching

Volume 530: debated on Thursday 23 June 2011

Motion made, and Question proposed, That this House do now adjourn.—(Stephen Crabb.)

I thank the Minister for being present to respond to the debate. I understand that he is in some matrimonial difficulty because I have delayed him here this evening and it is his wife’s birthday. If it is any compensation, I am sure that I can arrange for his wife to be given a free bleaching treatment quite soon—on the understanding that he explains to her that it is free, so that he does not get away with allowing her to think that she has been presented with an expensive gift.

Let me first declare a simple interest and then add to it, because of the specifics of the debate. I am a qualified and practising—although admittedly very part-time—dentist. I am also a member of the British Dental Association, the British Academy of Cosmetic Dentistry, the British Endodontic Society, and the British Dental Bleaching Society. That explains why I am a target for some 36,000 dental practices which are leaning on this issue. I hope that the Minister will bear with me.

The Minister will be aware that tooth bleaching by dentists has been around for a long time. I first used it about 30 years ago. My tutor was my now retired dental partner, who qualified during the second world war, and his tutor was his father, who qualified shortly after the first world war. Dental bleaching has therefore been used for more than 100 years. In the early days we used a 30% solution of hydrogen peroxide, known in those days as Superoxol. It was extremely destructive of soft tissues, which needed to be protected. In those days we used something called a rubber dam, which was a small sheet of latex rubber with holes placed in it so that the teeth could poke through. The teeth could then be bleached, and the soft tissues were looked after.

The aim of bleaching is to remove discolourations from the teeth without harming the teeth themselves. The discolourations can come from a number of sources, including tobacco, hard water, tea, coffee and, according to the actresses, red wine. Teeth may also be iatrogenically discoloured, the most famous example being tetracycline discolouration. In the early days of antibiotics, children were given an antibiotic called tetracycline, which was one of the early broad-spectrum bacteriostatic antibiotics and was widely used. Although it generally dealt with the targeted infection, if taken by children it discoloured the developing teeth, sometimes to a grotesque degree.

Second or adult teeth that have received a blow can often darken quite quickly, particularly if the individual is young. The teeth most frequently hurt in that way are the upper incisors, particularly the upper central incisors. Endodontically treated teeth often darken, particularly if the operator has been unable to remove, or has not removed, all the pulpal tissue from the internal dentine.

Nowadays, dental restorations are generally of a more cosmetically acceptable material. If someone is to have a filling, it is good for it to be done in a cosmetically acceptable way. It is becoming increasingly accepted as standard practice that when composites, porcelain crowns, porcelain veneers and porcelain inlays are used for restorations, it is sensible to bleach the teeth first. That achieves a benchmark colour to which the new restoration is then colour-matched. As the patient’s teeth become discoloured over subsequent years from all the hazards, including red wine, it is possible to use that same process to bring the teeth back to that original benchmark level.

Dental bleaching is not available on the national heath, but I believe that in some cases it should be, because it is less destructive than other options. To provide a simple example, if an NHS patient has badly tetracycline-stained teeth, the only option on the NHS to restore normal appearance is extensive crowns or veneers. They are destructive to the teeth and much more costly, and in time they will need regular replacement. The better approach is dental bleaching, which leaves the teeth intact and can produce an acceptable colour.

Techniques of dental bleaching have improved. First, the dentist has to check that the patient’s teeth are in good order; then there are essentially two different bleaching techniques available. The first is the so-called home technique, whereby after inspecting the patient, the dentist constructs close-fitting trays that the patient wears for a period of time at home. The bleach trays are designed to hold the gel against the teeth but away from the soft tissues.

The second method is so-called power bleaching, which is done in the surgery and generally uses much stronger hydrogen peroxide concentrations. The soft tissues are protected by either the aforementioned rubber dam or, more generally nowadays, by a foam that is set by an ultraviolet light. Some techniques use a light or heat source, although I personally believe that that is more for the image of the procedure as the patient sees it than to benefit the process.

Nowadays, hydrogen peroxide is generally delivered in varying strengths of carbamide peroxide. Those strengths vary from 10% to 38% when used in the surgery. The actual hydrogen peroxide concentration delivered is lower. For example, 10% carbamide peroxide delivers approximately a 6% concentration of hydrogen peroxide. As logic will tell the Minister, the higher the concentration, the faster the bleaching, but the more likely it is to produce sensitive teeth.

I hope that the Minister understands from what I have said that the procedure should be in the hands of a trained dental professional, as misuse can cause harm, sometimes extensive harm. Even bleaching at home must be under the direction of a dental care professional. Recent decisions of the General Dental Council have stated that dental bleaching by trained dental professionals is a part of professional dental treatment. That has been endorsed by the Secretary of State for Health and the Health Ministers of Scotland, Wales and Northern Ireland.

The reason for this preamble is to explain to the Minister that the dangers of the material involved when it is misused must be understood and taken into consideration. Organisations such as the British Dental Bleaching Society run certification training courses to ensure that the dental professional teams undertaking the treatment are properly trained. Unfortunately, a number of non-dental professionals, particularly in beauty salons, are illegally bleaching teeth. Sadly, some of those individuals are using a material called chlorine dioxide, which, although it produces an initial appearance of whitening teeth, actually badly damages them.

As the Minister will be aware, the fly in the ointment is the European cosmetics directive, which restricts the sale of tooth-bleaching materials containing more than 0.1% hydrogen peroxide. Clearly that makes eminent sense when applied to over-the-counter medicines, but from a dental treatment point of view 0.1% hydrogen peroxide is absolutely useless.

The enforcement of the cosmetics directive is in the hands of local government trading standards officers on behalf of the Department for Business, Innovation and Skills. Most trading standards officers recognise that higher concentrations of hydrogen peroxide delivered as part of dental treatment by dental professions are completely different from over-the-counter sales or the actions of non-dental professionals. The directive is inappropriate, because tooth bleaching is accepted as part of dentistry.

In 2005, the European Commission scientific committee on consumer products recommended that tooth-whitening products containing 0.1% to 6% hydrogen peroxide are not safe to be sold over the counter. The recommendation was that they should not be used freely, but that they are safe to be used after the approval, and under the supervision, of a dentist. Since then, the UK Government, along with most EU members, have been trying to change the directive in the light of the recommendation. However, because two or three EU members of the committee keep baulking, there has been no change, despite seven years of pressure. I understand that the Minister could reassure me tonight that the issue is to be taken above the committee, where it is expected to be passed—at last—by a majority vote.

However, the situation has come to a head locally, as the Minister is aware. A patient of a Hull dentist complained to Hull trading standards. Hull trading standards took samples from the dentist and asked Essex county council trading standards to investigate a firm called Dental Directory, which is a major supplier to dentists and the supplier to the Hull dentist in question. I believe that Essex trading standards officers have taken the names of other suppliers and suggested to respective trading standards organisations that they should investigate. Some did so, but others thought it through and decided that that was inappropriate.

After full consideration, Essex trading standards sent an e-mail to Dental Directory, which states:

“This Service has no issue with peroxide-based whiteners over 0.1% supplied to GDC registered dentists for use in the course of a professional whitening service conducted by a registrant. It is the view of this Service that such treatments would be regulated by the GDC.”

That is a brilliantly sensible response.

However, another big firm of suppliers, Henry Schein, has a number of different depots in different areas, which are covered by different trading standards. It has received differing instructions. Kent trading standards echoed Essex’s eminently sensible position, but Medway trading standards informed Henry Schein that it is not allowed to supply dental bleach with over 0.1% hydrogen peroxide. Needless to say, enormous pressure was applied. I suspect to the Minister’s relief, Medway has reverted to the sensible Essex county council position.

That leaves me with two simple requests for action to sort out this particular nonsense. First, I urge the Minister, if at all possible, to obtain a change in the directive, and secondly, to inform all UK trading standards that the approach taken by Essex and Kent trading standards should be the norm.

As the Minister may recall, a few moments ago I mentioned beauticians and non-registrants illegally bleaching teeth. Many of those people are dangerous. For example, a plasterer from Kent plasters walls during the day, and bleaches teeth in people’s homes in the evening, using 38% hydrogen peroxide, with no guards or safety measures. To put it bluntly, he probably burns the gum off the bone and the teeth. He is dangerous.

Others use chlorine dioxide. As the Minister’s school chemistry will tell him, when chlorine dioxide hits water, as in saliva, it turns to hydrochloric acid, and eats the enamel surface off the teeth. The initial slight whitening appearance turns, on further applications, yellow and then brown, as the dentine shows through because the enamel disappears. To put it bluntly, that simply wrecks teeth.

To add to those problems, a number of highly acidic tooth-whitening products are available over the counter for personal, home bleaching. Many are highly acidic. All the highly acidic ones are highly damaging. To my amazement, even two reputable UK pharmacies—I am not naming them for the moment—are selling such products over the counter. I am therefore also asking the Minister to assist, through trading standards, in stopping beauticians and other non-dental registrants bleaching teeth. The General Dental Council is taking action, but it does not have the strength and spread of trading standards.

In addition, will the Minister seek a ban on the use of chlorine dioxide for teeth bleaching, including on the supply of acidic, over-the-counter home bleaching materials? An awful lot of smiles on the faces of some very pretty young ladies are being wrecked in the United Kingdom.

I congratulate my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing this important debate. It is not the first time he has come to the House to campaign on this issue—he deserves a lot of credit for his persistence and determination. This is a serious issue for those adversely affected by people using certain materials they should not be using, as he explained. I also thank him for the offer to my wife—I will convey it to her later this evening.

This is a complex matter involving overlapping issues, which my hon. Friend highlighted. Particular factors to consider are: first, that the current European-derived law clearly restricts the level of hydrogen peroxide to a level at which it cannot bleach teeth. Secondly, prevailing scientific opinion on the safety of hydrogen peroxide in teeth-whitening products is out of step with current maximum limits. Thirdly, how do we most appropriately enforce the law? Fourthly, who should be undertaking teeth whitening? Should the role be reserved to dentists or should it be available from other suppliers and even for home use? Finally, there is the issue about the safe use of other substances used as an alternative to hydrogen peroxide.

Although I recognise how deeply frustrating this matter is for all involved, I will try to address these points and highlight a possible resolution of the issue. I hope that I can give my hon. Friend some satisfaction tonight, but if there are other points he wishes to make that he feels have not been covered, I will be happy to correspond with him, and if necessary meet him. There is no doubt that teeth-whitening products are cosmetic products within the meaning of the cosmetic products directive. Hon. Members will know that the UK has been pressing for a number of years on the cosmetics regulatory committee for the maximum limit for hydrogen peroxide to be increased in line with the opinion of the scientific committee on consumer products in 2005, to which my hon. Friend referred.

The scientific committee’s view was that allowing a greater percentage of hydrogen peroxide in teeth-whitening products would not be detrimental to the health of consumers. Since then, however, there have been protracted discussions in Brussels on matters of detail. We are now in the position where the European Commission has proposed a number of directives to amend the cosmetic products directive, each of which has failed. The latest was submitted to the standing committee on cosmetic products for vote by written procedure in May last year, at which time five member states voted against the proposal.

The Commission was therefore required to reconsider its proposal, and has since amended the directive. Instead of putting it back through the regulatory standing committee, the Commission intends to submit it to the Council for a council directive. Let me explain the detail of this new development. The Commission believes that use of teeth-whitening products containing more than 0.1% and up to 6% hydrogen peroxide can be considered safe if the following conditions are satisfied: first, if an appropriate clinical examination takes place to ensure the absence of risk factors; and, secondly, if exposure to the products is controlled to ensure that they are used as intended. Teeth-whitening products should therefore not be directly available to the consumer. For each cycle of use, the first use should be limited to dental practitioners or under their direct supervision. This will be communicated to the Council before the summer break, and we will support it.

I note that the General Dental Council considers tooth whitening the practice of dentistry, which is limited to GDC registrants, and this ties in with the new proposal for a directive. Indeed, earlier this year the GDC successfully prosecuted a non-registrant under the Dentists Act 1984. I would urge members of the public who have received a treatment about which they have concerns to raise it with the GDC. This also applies where alternative teeth-whitening treatments, such as chlorine dioxide, are used with unsatisfactory or damaging results. My officials will contact the Commission about the concerns of the British Dental Association over the use of chlorine dioxide in teeth-whitening products.

On the question of enforcement, I understand that there have been concerns about investigations carried out by trading standards services into the supply of teeth-whitening products, some of which contained significant levels of hydrogen peroxide—more than the newly proposed amendment would permit. Trading standards services have a duty to enforce the Cosmetic Products (Safety) Regulations 2008, but they take a risk-based approach to enforcement. To our knowledge, they have never actively targeted dentists, but where suppliers are marketing home-use kits, they have a responsibility to investigate where such products could reasonably present a risk to the consumer.

My Department neither controls nor directs trading standards services in their enforcement activities. However, officials will be making them aware of the latest developments in Brussels on the issue, so that they can understand the direction in which the law is likely to develop. Officials have also been in contact with many of the trading standards departments looking into the matter to ensure that a consistent approach will be taken. Decisions on whether to progress investigations into suppliers of home-use kits will remain decisions for local authorities. It is unfortunately true, however, that many suppliers of teeth-whitening products have already anticipated a change in the law, which has made the task of trading standards officers extremely difficult over the past few years. On a separate but closely related note, I am pleased to say that a new and specific element on enforcement will shortly be added to the red tape challenge. We would encourage businesses to go on the red tape challenge website and tell us about the problems they are having with the implementation of regulations.

In conclusion, I hope that I have been able to shed light on the latest developments, which could offer a way forward on this protracted issue. Subject to agreement in Brussels, the new directive will clarify the law. I also believe that the decision of the General Dental Council will help to clarify the position on the provision of teeth-whitening services. I am grateful to my hon. Friend for enabling me to put that on the record, and I hope that he and the dentists on whose behalf he has so persistently advocated will be pleased with it.

Question put and agreed to.

House adjourned.