The question is no longer whether to sell home-care products in the dental office, but rather what products we should offer.
Bernard Schechter, DDS
Only 15-25 percent of all general practitioners provide their patients with the opportunity to purchase some home-care products. When home-bleaching kits are added to the picture, that figure goes much higher - probably exceeding 70 percent of offices!
So, the question no longer is whether or not to sell home-care products in the office, but rather what products we should offer. The concept that it is not "professional" to sell products in the dental office is as obsolete as the concept that it is not "professional" to market dentistry through advertising.
The number of dentists who advertise in Yellow Pages display ads, newspapers, magazines, radio, local cable-access TV, direct mail, newsletters - and now via the Internet - has increased many fold over the last two decades. Increasing just as rapidly - if not faster - are the number of dental offices that sell home-care products to patients.
If done properly, this results in a true win/win situation. Patients enjoy the convenience of purchasing home-care products at their appointments, and they are instructed on how to use those products properly. That means they can begin using them the same day. The office staff gets the satisfaction (and relief) of knowing that patients have purchased the correct products for their home care, and that they have been properly instructed on how to use them. The practice also earns a well-deserved profit from the sale of the products and/or the staff`s time spent in educating the patient about using the products.
In the early 1990s, a speaker I was listening to at a dental seminar made a very interesting comment. He said that the dental "patient" was rapidly becoming the dental "consumer." How accurate this scenario is in the newly initiated 21st century! For example, patients read about bonding and veneers in Cosmopolitan, Vogue, or Esquire. They ask their dentists questions based on this information. Sometimes, patients` decision on whether or not to actually proceed with esthetic restorations are based upon the answers they receive to their questions. Sometimes, even patients` decisions about whether or not to have a particular dentist do their case is based on the answers to questions raised in one of these articles. Like other businesses, the dental practice also is subject to some form of consumer pressure, the consumers here being patients - either existing ones or potential ones.
Media advertising and editorials have made millions of people aware of oral-health issues. The relationship of periodontal pathogens to stroke, cardiovascular disease, ulcers, aspiration pneumonia, and premature low-birth-weight babies has been scientifically documented, and it has received a lot of press. Additionally, the large pharmaceutical companies have devoted millions of dollars to advertising that their products can "kill the bacteria that cause gum disease." Patients are asking very serious questions about the accuracy of this information and what they can do to prevent problems or treat existing periodontal disease.
Issues such as periodontal health, halitosis, caries control, and tooth-whitening bring with them the choice of many different home-care products. Patients often turn to the dental office for guidance regarding those products. They frequently ask dental staff members if they know of any home-care products that might be even more effective than the ones they currently are able to obtain from retail stores.
In fact, some people actually become patients in offices where certain products are sold. This occurs because they belive those practices that provide high-quality home-care products also provide high-quality dentistry.
Before we discuss how to market home-care products in your practice, let`s first discuss the various types of products available.
They are not "home-care products" in the true sense of preventive or therapeutic use. They are a "home-service product." These at-home, professional bleaching products provide a way for patients to gradually lighten their teeth, resulting in a more positive self-image. A whiter smile can make people feel better emotionally and psychologically.
Most of these professional home-bleaching kits contain 10-22 percent carbamide-peroxide gel or foam. They are designed to be used overnight in custom trays. The 7.5-9.5 percent hydrogen-peroxide kits are designed for shorter daytime applications. Various manufacturers add other ingredients, such as fluoride for remineralization and potassium nitrate to minimize sensitivity. Professional home-bleaching kits are made by a number of manufacturers. Some of the more popular kits are:
- Nite White® Excel 2 (Discus Dental)
- Opalescence® (Ultradent)
- Platinum (Colgate)
- XTRAComfort™ Take-Home Kit (Den-Mat)
Home-bleaching kits can be a significant part of the profit from in-office product sales. They can make a substantial contribution to the practice`s bottom line. In addition to the positive effect they have on a practice, they contribute to the emotional well-being of some patients. They are a good example of the positive effect modern dentistry can have on people`s lives.
The dentist first must determine whether a patient requires neutral sodium fluoride (NSF) or acidulated phosphate fluoride (APF). NSF is used for caries reduction, remineralization, and relief of sensitivity. APF is utilized for caries reduction, enhanced remineralization, and reduction of hypersensitivity. Examples of product groups include:
(1) 5000 ppm F, 1.1 percent NaF dentifrice
a) Prevident 5000 plus (Colgate)
b) ControlRx (Omnii)
c) Fluoridex™ Paste (Discus)
d) Nutra Care (Oral-B)
(2) .4 percent stannous fluoride brush-on gel or paste
a) Gel Kam (Colgate)
b) Omnii Gel (Omnii)
c) Perio Plus Paste (Discus)
d) Stop (Oral-B)
(3) .63 percent stannous fluoride rinse
a) Gel Kam Rinse (Colgate)
b) PerioMed (Omnii)
c) Perio Plus Rinse (Discus)
As you can see, different manufacturers produce similar products under their own brand names. Some products are prescription and some aren`t. It`s up to the individual dentist to make a decision about which products he or she will carry in the office. Whatever the decision, remember: It is an established fact that a large percentage of prescriptions are never filled. That`s why having the types of products we`ve discussed on hand is a real service to your patients.
Research has shown that the primary cause of bad breath in 90 percent or more of halitosis cases originates in the mouth. Anaerobic bacteria living in the deep cracks and crevices of the tongue dorsum metabolize exfoliated tissue cells. The digestion of dead cells by these microbes produces by-products such as hydrogen sulfide and methyl mercaptan, the volatile sulfur compounds (VSCs). It is generally accepted that the odor of these noxious gases is a major factor in varying degrees of halitosis.
Clinical Research Associates (CRA) of Provo, Utah, has conducted an extensive - and still ongoing - "Fresh Breath Study." CRA found that Tooth&Gum Tonic (Dental Herb Company), a product developed for periodontal purposes, and Oxygene (Oxyfresh Worldwide), produced the longest-lasting results in combating halitosis.
Manufacturers` claims vary so much that dentists frequently are confused about which products to prescribe. It`s not surprising, then, that patients also are confused about which products to use. Various systems utilize different active ingredients to counteract the bacteria and the VSCs. For example, four of the most widely used antihalitosis products use quite different approaches in their formulations:
(1) Tooth&Gum Tonic (Dental Herb Company) uses pure essential oils and organic herbal extracts.
(2) Oxygene with Zinc (Oxyfresh) uses stabilized chlorine dioxide and zinc acetate.
(3) Breath Rx™ (Discus Dental) uses zytex, a compound of zinc chloride, thymol, and eucalyptus oil.
(4) BreathCare™ (Den-Mat) uses 3 percent carbamide peroxide.
The above four products are sold only or primarily through dental offices. Patients basically must rely on their dental professionals to make these products available to them. Many offices offer two different types of antihalitosis formulations, taking into account variations in individual patients` needs and tastes. Making the most effective antihalitosis products available (even without a "program" in place) is providing a wonderful service for the patient, while earning a well- deserved profit for the practice. If the product(s) offered are only available professionally, this makes providing them that much more of a service.
Mechanical cleaning of the tongue is an integral part of any halitosis (or periodontal) program. There are dozens of "tongue scrapers" on the market with different shapes, sizes, and angles. They are too numerous to list and have lots of similarities. Examples are:
(1) Oolitt Elite (Oolitt Advantage Inc.) - This is the best known brand in the dental profession. It has a variety of different instruments to suit different mouth types including, the Oolit Jr. for children.
(2) Breath-So-Fresh (IDDS)
(3) Breath Taker (Medical Innovations)
(4) Tooth Slooth (Professional Results Inc.)
Periodontal-health maintenance products
The 1990s saw a major shift, both ideologically and clinically, in the way dentistry understands the etiology of periodontal disease. Research has shown that periodontal disease is a bacterial infection.
Barring any unusual patient metabolic irregularities, the cycle of periodontal disease goes something like this: obligate and facultative, gram-negative anaerobic pathogens are living subgingivally. In the course of their metabolic cycle, these bacteria excrete waste products known as bacterial toxins. The human immune system responds to these toxins by secreting enzymes to neutralize them. Enzymes such as collagenase, elastase, and hyaluronidase are secreted. While they may do their neutralizing job well, these enzymes break down such structures as the collagen and elastic fibers that are major components of the periodontal-attachment apparatus. The hyaluronidase breaks down hyaluronic acid, the "ground substance" between tissue cells. It basically is the body`s own immune system responding to bacterial toxins, which breaks down the periodontium.
A growing percentage of general dentists are realizing that periodontal surgery is not always necessary to resolve a case. In some instances, surgery can be deleterious to the dentition and should be avoided if conservative methods of treatment can be carried out successfully. In-office procedures such as deep scaling, curettage, and some light root-planing must be supported by - and, in fact, may even become secondary to - patient home care. If a patient`s teeth are "cleaned" 25 times a year, that still leaves 340 other days in which subgingival activity must be dealt with. The dentist or the hygienist must communicate the importance of home care to the patient and provide instruction about how this maintenance is to be performed. Have available, in-office, the proper products for the patient to take home and hopefully begin using that same day.
Patients know about the issue and are very concerned from a general health point of view. They have many questions for their dentists and hygienists about which products are best for their home care. It behooves dental health-care professionals to have some familiarity with the oral home-care market so that they can guide their patients in product selection. It is no longer only a matter of periodontal health; the health of the entire body can be affected by the health of the mouth. An overwhelming amount of data supports this fact.
We all know about premedicating certain patients with antibiotics (before scalings) to prevent bacterial endocarditis. The subgingival microbial population also must be controlled to prevent disease of the blood vessels, heart, stomach and intestines, lungs, and, possibly, the unborn. This is not a joke. It is a serious issue, and we must pay attention to it.
Tom Baldwin, DDS, MAGD, of Towson, MD, is the editor of the Newsletter of Non Surgical Periodontics. This quarterly publication deals with many of these issues and more, including scientific validation through the literature, as well as practical guidance for the dental team on implementing therapies into the practice.
Oratec Corp. of Manassas, Va., has a catalog with the most comprehensive selection of anti-infective periodontal products. They sell many different items from different manufacturers. Their catalog contains such things as phase contrast microscopes, mechanical and hand-held irrigators, cannulas, anti-microbial rinses, and irrigants. They also have books about anti-infective therapy and information about oral-microbiology testing services for difficult cases. I suggest that you obtain this catalog. It is an eye-opening introduction to certain products that will help your patients with their home care, as well as help the dental team provide more comprehensive in-office treatment.
Products for periodontal home care can be divided into two main categories:
- Medicaments (consumables)
- Mechanical devices (delivery systems)
(1) Mouth rinses - The shelf space allocated to mouth rinses in pharmacies and supermarkets has nearly doubled in the past decade. As the public continues to become more aware of the relationship between periodontal disease and systemic disease - and also about the bacterial component of halitosis - the demand for antimicrobial mouth rinses dramatically increases. Large pharmaceutical companies that manufacture such products as Listerine, Scope, Act, Plax, Viadent, etc., have flooded the consumer market with media campaigns. If the dentist wants to go beyond handing out free samples of commercially available mouthwash to recall patients, a number of options are available for in-office sales.
Examples of rinses that are only obtainable via prescription, by dentists` referral of patients to manufacturers, or that are only sold through professional offices include:
a) Chlorhexidine Gluconate .12 percent - Despite the problems with staining and taste, CHX still is the most widely used anti-microbial rinse in dentistry. Wholesale prices to dental offices have dropped considerably in the past few years. This makes it possible for patients to purchase the rinse through the dental office at competitive prices, while still allowing an excellent profit for the practice. CHX .12 percent is available directly through dental offices only or by prescription at pharmacies. Examples of CHX .12 percent are:
- Perioguard (Colgate)
- All of the other identical products which manufacturers have packaged under their own labels.
b) Therasol (Oratec) - The active agent is C31G, an amphoteric molecule that simultaneously possesses positive and negative charges. It is available through dental offices or by a dentist`s referral of a patient to the manufacturer.
c) Tooth&Gum Tonic (Dental Herb Company) - The active ingredients are pure essential oils and herbal extracts. It is alcohol-free and available through dental offices or by the dentist`s referral of a patient to the manufacturer.
d) BreathCare™, Breath Rx™, Oxygene, and several other anti-halitosis products have positive periodontal uses in the dental market.
Since the subgingival periodontium is subjected to reinfection from the intraoral mucous membranes and the dorsum of the tongue, rinses are really good for patients to use! Having a high-quality antimicrobial mouth rinse for patient purchase is definitely a positive.
(2) Subgingival irrigating solutions
a) Solutions for hand-held syringes and pocket irrigators - Any antimicrobial mouthrinse recommended to patients also should be used as a subgingival irrigant in a nonelectrical, hand-held applicator. This also holds true for use with interdental brushes and applicators.
b) Solutions for Mechanical Irrigators - Mechanical devices such as the Viajet or WaterPik require a different concentration of product then do their hand-held counterparts. Generally speaking, it is not cost-effective to use undiluted mouthwash in a mechanical irrigator. Diluting the mouthwash too much can reduce its effectiveness. Chlorhexidine can be used in a mechanical irrigator, but it is quite costly. It is more economical in a hand-held syringe. Therasol can be used straight up, but it also can be used in a concentrate that can be diluted for irrigator use. Oxygene with zinc is recommended by its manufacturer for use in mechanical irrigators. Dental Herb Company manufactures Under The Gum Irrigant, a product specifically formulated for use in mechanical irrigators.
(3); Toothpastes (antimicrobial or antihalitosis) - We don`t even have to get into it! Most of the manufacturers of periodontal rinses, irrigants, and antihalitosis products also make toothpastes. Make available to your patients the dentifrice that is most harmonious with the other products they use at home.
(1) Manual toothbrushes - The major manufacturers such as Oral-B, Colgate, and John O. Butler do not want dental offices to sell manual toothbrushes to patients. It conflicts with their programs for product sales in retail outlets. Note that the toothbrushes you purchase for the office all have printed on the box "Not for retail sale" or something similar. No reason to push it. Build these types of toothbrushes into the cost of a recall appointment and don`t plan to pay down your equipment loan from the sale of manual toothbrushes in your practice!
(2) Power toothbrushes - There are a bunch of different ones on the market. Some of the more popular ones are sold in retail stores, yet are also available through dental practices. The various manufacturers make some very strong claims about their products (and the products of competitors!). The differences are in the size and shape of the brush head, handle design, and the type of functional movement the instrument makes.
Examples of the more popular ones that are sold both in stores and dental offices are:
- Sonicare® Plus (Optiva)
- Interplak (Conair)
l Plaque Remover (Oral-B)
Examples of instruments sold only through dental offices are:
- Rotadent (Pro-Dentec)
- Sensonic 150 (WaterPik Technologies)
Revenues from power toothbrushes can amount to a significant part of in-office product sales.
(3) Interproximal or interdental brushes and applicators - Originally designed to remove plaque accumulations in difficult-to-reach, interproximal areas between natural teeth, fixed bridgework, and around orthodontic appliances, these handy devices also can serve as delivery vehicles for various antimicrobial solutions. Some brands have foam applicators designed for this purpose, and others rely on the brush itself. They can be sold to patients or built into the cost of a soft-tissue-management program. Most manufacturers also offer a travel version of the standard models. Don`t give them away - they are too costly!
Examples of better-known brushes and applicators include:
- Sulcabrush (Sulcabrush Inc.)
- Proxabrush (John O. Butler Co.)
- Interdental Brush System (Oral-B)
- Curapox (Curaden Ltd.)
(4) Patient home irrigators (hand-held and mechanical) - Gram-negative anaerobic pathogens living in deeper periodontal pockets (5mm or more) basically are untouched by conventional flossing and brushing. Rinsing with proper antimicrobials has some effect, but subgingival irrigation produces the best results.
Hand-held irrigators can be quite effective, especially if the hygienist will spend a few minutes instructing the patient on proper technique. Use of a hand-held irrigator to deliver antimicrobials subgingivally can produce some pretty amazing results. Examples include:
- Pocket Care (SDI Laboratories)
- Perioflex (Oratec)
- Monoject Syringe fitted with side-port cannula
Electrically-powered irrigators are the best way to deal with subgingival pathogens in more complex cases. The primary function of a mechanical irrigator is to disrupt the bacterial mass and deliver anti-microbials subgingivally. There are differences in tip design, reservoir capacity, controls accessibility, and cost. Two brands of irrigators have magnets that they claim change the polarity of the water and affect the amount of calculus formation. These "irrigators-with-magnet" cost the patient two to three times as much as the type without the magnet. The dentist will have to decide which combination of benefits and cost best serves the needs of each individual patient.
The most commonly used mechanical irrigators without the magnets are:
- Viajet (Oratec)
- Water Jet (Interplak)
- Water Pik® (WaterPik Technologies)
Irrigators with a magnet include:
- Hydrofloss (Hydrofloss Inc.)
- Oxycare 3000 (Oxyfresh)
Any reduction in the subgingival pathogens reduces the risk of spreading these microbes to other parts of the body. Providing your patient with proper medicaments and delivery systems for home-care use may prevent systemic disease or even save a life!
Giving your patients the opportunity to purchase select, effective products from your office will result in them having even more respect for the practice. They will respond to your caring participation in their home-care, oral-health programs by allowing you to do more high-quality restorations in their mouths. They also will respond by referring more friends and relatives to your practice. You will feel rewarded by helping your patients acquire the right tools to properly maintain their mouths at home ... and by the increased revenues and profit your practice will experience!
As I said at the beginning of this article, this is truly a win/win situation. But I`ll have more about that when we discuss how to make this happen in the September issue. We will cover topics such as how to use in-office product sales to enhance your practice`s image, which staff members should discuss products with patients, how to display or stock products, how to internally market products, and how product sales can reactivate "dormant" patients ... and more. I`ll be back next month to help you put this stuff into practice - yours!
What`s really professional?
For those of you who still have some issues with "selling" products in the dental office and this being "unprofessional" or a "conflict of interest" or whatever, please consider the following: The demand for home-bleaching kits is very strong. Do we tell our patients to go buy a $39.95 home-bleaching kit on "special" at the local pharmacy or to purchase a bleaching kit from one of the TV shopping channels? No, we don`t, because we know that many of these "over-the-counter" products have poorly fitting trays and inadequately formulated gels that either don`t work properly or even can harm tissue.
It`s in the patient`s best interest to purchase a home-bleaching kit from his or her own dentist (at an average price of $400 for both arches). The fee for this service includes the cost for an assistant to make impressions in order to fabricate properly contoured and trimmed custom trays, and then to spend an adequate amount of time instructing the patient in the proper use of the product.
The home-bleaching kit costs the office about $45. The cost of impression materials and one hour of an assistant`s time is about $20. Take the $400 fee minus the expenses of $65 and you have a profit of $335. The service to the patient in this scenario - oftentimes, awesome! The dentist`s time used for this service - basically none. Did we charge $335 for an hour of the assistant`s time ... or did we make a profit, a mark-up, or whatever you want to call it on the home-bleaching kit?
Few dentists object to dental offices providing home-bleaching kits to patients at a price eight to nine times the cost of the kit itself. For most, this is a perfectly acceptable fee-for-service arrangement. If it is alright to provide this vehicle for cosmetic home care, how much more acceptable or even desirable it is for us to provide our patients with the opportunity to purchase certain home-care products ... products that will help them keep their teeth longer, enjoy a better quality of life, and reduce the risk of systemic disease via transmission of oral pathogens to other parts of the body.
If a dentist feels that a certain formulation is highly effective for his or her patients - and this product is not available in stores, but only available through dental offices - perhaps it is "unprofessional" not to sell it! Stocking select items for sale to patients serves as a convenience for them, encourages compliance, and establishes what could be substantial profit for the practice.
By being sensitive to your patients` needs and stocking select home-care products, you are providing a much-needed service that patients really appreciate. This often sets an outstanding tone and energy to the office, identifying it as more "cutting edge" than practices that don`t provide such services.