crown & bridgeStart with bleaching

Nov. 1, 2003
There is a common saying, "When all you have is a hammer, everything looks like a nail." This is certainly the case in many aesthetically-oriented offices when the only skills the practitioner has to offer to patients seeking smile makeovers are porcelain crowns and veneers.

Jeff T. Blank, DMD

There is a common saying, "When all you have is a hammer, everything looks like a nail." This is certainly the case in many aesthetically-oriented offices when the only skills the practitioner has to offer to patients seeking smile makeovers are porcelain crowns and veneers. Easily recognized as the most expensive options for creating a dazzling smile, fees for these services can range from $700 to $2,000 per tooth. Regardless of whether you live in New York City or Rock Hill, South Carolina, presenting these services as the only means to achieving a bright, white new smile quickly separates the wheat from the chaff. In strong markets where economic stability and confidence are high, many offices can expect a decent volume of patients with liquid cash (who are willing to part with it!) seeking these monster treatment plans. But when unemployment is high, investment returns are down, and consumer confidence is low, even those patients who aren't broke are naturally reluctant to open the purse strings for these self-pampering cosmetic procedures.

In my practice, I have identified three key cosmetic services that every cosmetic practice should have in its toolbox. I have identified these services as essential because they can not only create dazzling cosmetic changes to those patients with not-so-perfect smiles, but they also can be performed at low fees with a high profit margins. These three, absolute win-win cosmetic crowd-pleasers are:

1) Vital tooth-bleaching
2) Direct posterior composites
3) Direct anterior composite veneers.
In this article, we're going to focus on bleaching.

Bleaching: the big ball of confusion

One of the biggest benefits of traveling around the country and being with thousands of dentists on a routine basis is that you learn very quickly that we are, thankfully, all very different! I find it amazing that services that are considered routine in some offices can be completely ignored and not offered in others. And while I rarely encounter practitioners who are "against" vital tooth-bleaching, the degree to which it is offered varies tremendously from office to office. Some offices consider this a cornerstone "moniker service" and offer a full range of bleaching techniques and products to every patient who comes in the door. Others do little or nothing to make patients aware that this service exists or to tell them about the benefits it can offer.

Trying to pinpoint the reasons for such dramatic differences is difficult. Though my impression gathered from talking to hundreds of doctors is far from scientific, I suggest that most of the differences are grounded in office philosophy or attitude, rather than faith in particular products or modes of delivery. I can say this boldly because I have found this to be true many times in my own office. I think that as dentists, we have a tendency to — consciously or unconsciously — form quick, sometimes inaccurate, impressions of certain services or treatment modalities. And unfortunately, these judgments sometimes prove to be our biggest obstacles to success and growth. Maybe more than any other service, vital tooth-bleaching falls into this category.

So before we can discuss how we can fully integrate this service into our offices and profit from it, we need to begin from a common paradigm concerning the role of vital tooth-bleaching in our practices.

Learn to "get out of your own way!"

It's taken me 15 years to achieve this "aha" experience, but I have learned that when it comes to my own success, I need to learn how to "get out of my own way!" Like many dentists, I can humbly say that I sometimes analyze things a bit more than I need to. Being academically oriented is certainly a foundation to being in the medical profession. Being a perfectionist definitely translates to quality in much of what we do. But being stubborn is not helpful to us, our practice, or our patients! Looking back at changes I've made in my treatment philosophy over the years, I realize that had I learned to recognize the true difference between being appropriately cautious and ridiculously stubborn, my practice could be 10 times what it is today. So many times I refused to even consider certain treatment modalities, techniques, products, equipment, marketing techniques or management styles for reasons that today, I can't begin to comprehend. When I analyze this problem, I have come to realize that more times than not, when I stubbornly refuse to embrace a new dental concept, it is usually because I have failed to be exposed to a paradigm that fits with my internal values.

Often, as dentists, we become exposed to fragments of ideas, and these small fragments are not sufficient enough by themselves to be assimilated into a practical philosophy that we can adopt. An example of this would be that we see new devices or techniques in trade publications or seminars, and though on the surface they look attractive, we can't seem to complete the cerebral calisthenics required to make them fit into our own personal practices. This goes beyond the decision of whether we can afford the product or use it correctly, and lies in fully addressing issues like how the new technique should be presented to patients, how our staff will embrace and support the new technology, our expectations of its performance, our patients' expectations of its performance, and other issues such as pricing of the service, convenience of delivery, and practical applications in everyday practice. This is a paradigm problem, and unfortunately, it is an issue that must be addressed when positioning a key service like vital tooth bleaching.

A bleaching philosophy everyone can embrace

If any office is going to fully integrate elective, cosmetic, vital tooth-bleaching, a well-developed office philosophy must be formed and adopted by the entire dental team. A team divided will not stand, and offices planning to increase the volume of vital tooth-bleaching treatments must be in agreement about how these services fit into the practice. Modern bleaching philosophies must take into consideration not only the most popular nightguard-bleaching protocols, but also the myriad of treatment options available today. These range from nondentist-supervised drugstore kits, to state-of-the-art light-assisted bleaching centers. To deny any of these categories exists — or that none are popular — is not grounded in reality. Through media marketing, consumer awareness is at an all-time high. Possibly like no other aesthetic dental service available, patients know for a fact that they have options ... and they are looking to you for advice! Form a definitive opinion as a team, create a treatment philosophy, and stick to it.

In Figure 1, I have outlined 10 basic facts — supported in the literature — to help you create your own bleaching philosophy. The literature references are available upon request by emailing me at [email protected].

Developing your bleaching philosophy

Over the years, I have found several key concepts that have helped me develop a functional bleaching philosophy.

Step one: Begin "at home." This means that you and your staff could benefit from a whiter smile yourselves, so start there! It's pretty hard to promote elective tooth-bleaching as a clinical team if you haven't optimized the color of your own teeth. The fact is, the best way to promote vital tooth-bleaching is by having an office full of employees with dazzling white smiles to serve as examples to your patients.

Step two: Assume that all your patients would benefit and desire whiter, cleaner smils. You can check for interest with written questionnaires, but I find it far more effective to just ask patients if they've given any consideration to bleaching. These days, nearly every patient who walks in the door has heard about teeth-bleaching through television, radio, or print ads, and many have done research about it on the Internet. The goal is to open the door to a discussion, and not to offend or accuse people of having "yellow teeth." That's why you must word your questions carefully.

Frequently, patients present with existing dental restorations that are either faulty or an undesirable color, shape, or contour. Old, opaque porcelain-fused-to-metal crowns with dark margins and faded or stained composite restorations are just two examples of situations that are routinely encountered.

Often, patients are seeking replacement of these restorations because of poor appearance or because, during an exam, one or more of them is found to be faulty and in need of replacement for functional reasons. I suggest this be a mandatory time to discuss bleaching — before replacement begins. The rationale here is that when these restorations are updated, they will need to match the surrounding dentition to be serviceable. My comment to the patient is, "If you have ever considered optimizing the natural shade of your smile, now would be the appropriate time to do so." What you want to avoid is placing a new crown or a handful of Class III composites at an existing shade of A4, for example, only to have the patient ask you about bleaching immediately after you have finished. Always bring up bleaching first when considering dental restorations in the aesthetic zone. Give patients the choice to optimize their overall color first; then match their restorations to the newly-created shade.

A word about fees ...

One final tip — one of the biggest mistakes a practice can make is to overprice an elective, price-sensitive commodity like vital tooth-bleaching. Like it or not, inexpensive over-the-counter brands have negatively impacted the value of dentist-supervised services, and patients frequently are shopping for value. My personal feeling is that we need to seriously evaluate the cost of delivering these services and to keep access to the masses high. Practices that do a lot of bleaching always do a lot of other elective cosmetic procedures .

Figure 1
Basic Facts Essential for Creating a Bleaching Philosophy

1. Vital tooth-bleaching is safe. This service has been performed for over 20 years. Vital nightguard-bleaching has proven to be safe and effective since the late1980s.

2. Side effects are minimal. Reports of tooth or tissue injury in the literature have been few, and most are limited to pulpal inflammation due to excess heat from older wands and heat lamps to reversible and transient tissue burns with higher-concentration, in-office products. Modern lights are fabricated to keep pulp-temperature rise at a minimum, and properly-placed gingival barriers reduce transient tissue burns. Tooth sensitivity is common and transient.

3. Bleaching is not a surface phenomenon. Bleaching teeth occurs through free-radical production from the dissociation of unstable hydrogen-peroxide molecules as a result of contact with moisture and heat. It is not a surface "acid" that "eats off stains," but rather a radical-releasing substance that goes immediately between enamel prisms and into deep dentin and the pulp within seconds of contact. These radicals seek stabilization by attacking long-chain stain/pigments, breaking them up into less dense, less organized stain molecules. The longer the contact with the stain molecule — and the more radicals available to continue breaking it down —the lighter the tooth becomes. This is a time and concentration phenomenon, no matter what bleaching modality is used.

4. Bleaching can last for years. Studies show that because bleaching changes the internal and external color of the teeth, results can be stable for up to two years or longer. Of course this depends on patient habits, such as the use of chromagenic substances such as tobacco, colas, tea, coffee, red berries, etc.

5. Not all stains are created equal! Extrinsic stains break down first, deeper intrinsic stains take longer. Yellow/orange stains break down faster, while gray/brown stains take longer. Nearly all teeth will lighten over time ... but diligence and compliance are required. Remember, differing stains can exist in the same mouth, and variability does exist in terms of efficacy. Inform your patients of this, and let them know that if they are unwilling to assume the risk of unresponsive teeth, they must choose more invasive, definitive treatment alternatives such as veneers or crowns.

6. Bleaching is not dangerous to enamel. Bleaching does not significantly alter enamel. Minor alterations to surface smoothness do occur, but through natural remineralization, these changes are corrected quickly. Professional applications of fluoride may speed this process.

7. Is bleaching safe for immature teeth? To my knowledge, there have been no reports in the literature to indicate that bleaching harms developing or newly developing teeth. However, since this has not been studied well, caution must be exercised when bleaching immature teeth.

8. Bleaching causes transient sensitivity. Folks, this is a fact of life. Temporary tooth sensitivity is thought to be caused by several factors, including the transient increase of dissociated oxygen in the pulp of the tooth, possibly the transient permeability of enamel and root structure, and the dessication that occurs by placing an anhydrous formulation on the teeth for long periods of time. Different techniques and formulations of product can limit sensitivity. This is why it is important to offer more than one regimen of bleaching, and that doctors supervise and monitor the bleaching progress.

9. "Sick" or preoperatively hypersensitive teeth are not good candidates for bleaching. This is just common sense. If patients complain of hypersensitive teeth, it stands to reason that bleaching may not be their favorite pastime. Explore and treat the hypersensitivity first, then consider bleaching. If the cause is idiopathic, consider in-office protocols that minimize bleaching times.

10. Never promise a certain shade result to a patient. Bleaching results are highly subjective. Studies have proven that accurate determination of bleaching success is highly variable. Establish reasonable expectations with every patient. What seems "white enough" to you or a staff member may not meet your patient's goals.

11. Periodic "touching-up" may be required. The concept of recurring maintenance exists in nearly every other aspect of dental care, so why isn't it embraced with bleaching?

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