By Louis Malcmacher, DDS, FAGD
Tooth-whitening has been a boon to dentistry since it was introduced more than 15 years ago. It is a noninvasive procedure, works well on most patients, and is far less expensive than other aesthetic alternatives. Patients are very receptive to whitening procedures, because the results are very visible and dramatic.
When we first started doing tray-bleaching, we generally used a 10 percent formulation and told patients to bleach for four weeks one hour a day to obtain the desired results. Now, with tray-bleaching, we use peroxide formulations from 16 percent up to 30 percent peroxide formulations and tell patients that they can achieve results within five to seven days. There seems to have been a natural progression to one-hour whitening, and patients are very interested in this once they learn about it.
When should you use one-hour whitening in your practice? Say a patient comes in and says she has a wedding to go to in three days. Or, another patient's class reunion is in a week's time, and he wants to look his best. Say the patient is a gagger and cannot have alginate impressions taken for bleaching trays, yet he wants to have bleaching done. I have heard a variety of reasons for wanting one-hour whitening - from weddings to bar mitzvahs to first dates to just wanting to surprise a spouse with a brand-new, beautiful smile! We live in a world of instant gratification. Bleaching teeth is no exception.
All of the one-hour whitening systems basically work the same way. With all of these systems, soft-tissue protection and proper retraction is mandatory. This includes Vaseline on the lips, cocoa butter on the inside of the lips, cheek retraction, a tongue guard, and some kind of paint-on dental dam for the gingival tissues. The peroxide gels that are used for one-hour bleaching range in concentration from an activated 1 percent hydrogen peroxide up to a 40 percent carbamide peroxide. These are strong, toxic materials, making good soft-tissue protection a must. If the soft tissue comes in contact with the bleaching gel and the gel stays on it for a period of time, the tissue will turn white. Patients should be told to possibly expect a few of these white spots on their soft tissue after the procedure is completed. These whitish areas completely disappear in a few hours.
The first case of one-hour whitening that I did was on my wife, because I was excited to try this new concept ... and I couldn't think of a better guinea pig! I had done what I thought was a magnificent job of protecting the soft tissue. Her teeth responded wonderfully to the bleaching gel; she had nice, white teeth when we were done with the procedure. Unfortunately, when I took off the paint-on dental dam, my wife's gingival tissues had large white splotches. She asked me how long these splotches would last. Since this was the first case I had ever done, I really had no idea. I was sweating a good part of that day until those areas disappeared, and it actually took a couple of hours. The amazing thing about this is that she was not uncomfortable during the entire procedure!
Once proper retraction is in place, then you apply the peroxide gel to the teeth. Follow the manufacturer's instructions for best results. Generally, most manufacturers suggest placing the gel on the teeth and shining their proprietary light onto the gel. The gel should be agitated every few minutes and replaced about every 20 minutes for best results. Even with all of the soft-tissue protection that you have, you still should be careful not to force the gel under the paint-on dental dam or around the soft tissues. The exciting thing about this part of the process is that you literally can see the teeth turning white right before your eyes! Most companies use a clear gel so that you and your patient both can observe the process in real time.
Two related things are needed to bleach teeth effectively: they are concentration and contact time. The higher the concentration, the lower the contact time needed. This is true for tray-bleaching, as well as for one-hour, in-office power bleaching. If you are using a 35 to 40 percent gel and a light that emits both heat and light, then you only need about one hour of contact time. After an hour, remove the gel and take off all of the soft-tissue protection material. The teeth should be cleaned well with a prophy angle and pumice. If there is any lingering sensitivity, a fluoride treatment can be placed on the teeth.
What can you expect in terms of how much bleaching will occur? The general rule is that whatever level of bleaching you would have attained with the standard procedure of tray-bleaching over a two-week period is the level of whitening you can expect after an hour of in-office power bleaching. How about the issue of long-term relapse? Again, we look to tray-bleaching for the answers. This really varies from patient to patient. Some patients will have a significant relapse, while others will maintain, with little effort, a whiter, brighter smile for years to come. I always recommend a carbamide peroxide-containing toothpaste to my bleaching patients, such as Rembrandt Plus or Dazzling White™. The small release of oxygen from the carbamide peroxide in the toothpaste does help prevent bleaching relapse over the long term.
What about sensitivity? Well, let's not beat around the bush when it comes to this issue. Despite all of the manufacturers' claims - and having potassium nitrate desensitizing formulations - when you put a 30 to 40 percent carbamide peroxide gel onto teeth, you probably should expect some sensitivity with some patients. Again, this is a variable among patients, not among the bleaching gels. You've had the same experience when you use tray-whitening. Some patients will be sensitive, even if they put water in their bleaching trays. With other patients, you could put superoxol into their bleaching trays and they wouldn't feel a thing. As long as patients know to expect some sensitivity, they can deal with the issue much better than if they believe they will have absolutely no sensitivity.
"Beauty is pain" is an adage that many women are familiar with. Everybody knows that if you want to have pierced ears or a pierced tongue, there is going to be some "sensitivity" associated with it. You have to know your patient and be realistic about what to expect in terms of sensitivity.
For the most part, even when an occasional patient does have sensitivity, an analgesic (Tylenol or Advil), usually will do the trick, and the sensitivity will dissipate in a couple of days. We certainly are not going to go out of our way to create sensitivity for the patient, and we will do everything in our power to avoid it. This includes making sure the patient uses the desensitizing formulation of the in-office bleaching products, as well as providing a fluoride treatment after treatment.
Patient cost for one-hour bleaching usually is in the $600 to $900 range. Tray-bleaching has taught us that patients will pay for what they want. We all know that bleaching is not covered by insurance, yet millions of patients pay out of pocket for this service. Price has not been a barrier. As a matter of fact, people usually will pay more for the convenience of getting it all done in a short period of time.
Having a one-hour, smile-whitening program in your office will establish your practice as a state-of-the-art aesthetic center, offering many treatment advantages for your patients. One-hour whitening can improve a patient's appearance and confidence immediately. It gives patients what they want while creating a life-changing experience for both the patient and you.
A look at three one-hour, in-office bleaching systems
Here is an overview of three of the most popular one-hour whitening systems:
•The BriteSmile™ light system is exclusively available at BriteSmile Whitening stores or through a dental office that has signed up to become an Associated Dental Center. The whitening peroxide gel is approximately a 15 percent hydrogen peroxide formulation, which includes photo-initiators that match the BriteSmile light. The BriteSmile light whitens all of the teeth at the same time. It is typically left to shine on the gel, which is on the teeth for three 20-minute intervals. The light is a stand-alone unit that only can be used for teeth-whitening. The low concentration of peroxide requires a treatment time of approximately one-and-a-half hours.
The BriteSmile light comes to the dentist's office at what the company says is "no cost." However, to use the light, you will need to buy at least five BriteSmile kits at approximately $250 each, so there is a large, initial investment. BriteSmile recommends that dental offices charge $600 per one hour of bleaching. Some of the advantages of the BriteSmile System are strong patient marketing in certain areas of the country, ease of use, strong in-office marketing materials, and its success in bleaching teeth. BriteSmile also has an 800 number for patients to call, and operators will make appointments for patients in your office.
•Zoom!, by Discus Dental, is the newest addition to the one-hour market. Zoom uses a proprietary light and a 25 percent hydrogen peroxide gel for its whitening system. There is an initial investment to buy the light and then a cost per procedure for the materials that you need to accomplish the whitening process. The kit includes fluoride to remineralize the teeth, touch-up material, and a dual-barrel syringe for easier mixing and fresh materials. There are no contracts or leases with the Zoom chairside-whitening system. The advantages include ease of use and a whitening kit that comes with everything you might possibly need. The Zoom light features a low heat, which never rises above body temperature, keeping sensitivity to a minimum. The materials have a two-year unrefrigerated shelf life. Zoom is supported by a wide array of effective marketing, including in-office displays and brochures. The marketing thrust also includes extensive national advertising on TV, in print, and an 800 consumer number. Discus supports Zoom with in-office operational and marketing training. The Zoom light features a low heat, which never rises above body temperature, keeping sensitivity to a minimum.
•The Rembrandt® One-Hour Smile-Whitening Program uses a 35 percent peroxide formulation in conjunction with the Rembrandt Sapphire™ Light, a plasma arc light that accomplishes one-hour bleaching with an attached crystal that spreads the light. It also can be used for fast curing of composite resins.
Patients who walk into your office and see that you are a Rembrandt One-Hour Smile-Whitening Program member and will immediately relate this to the premium brand of toothpastes on supermarket and pharmacy shelves. Rembrandt has strong national advertising support with television commercials and ads in consumer magazines. There is a national hotline for people to call for recommendations to an office that is a member of the Rembrandt program. Rembrandt is known for its strong in-office marketing.
With the Rembrand® system, you can interchange the crystal with the curing tip and apply bleach to specific teeth that have not whitened as much as others. By doing this, you give these more resistant teeth an immediate boost to bring up the level of whitening to match the rest of the teeth. This system also has the easiest protocol, because it only requires one application of the bleaching material.