David A. Little, DDS
The smile remains at the core of your self-image. As the saying goes, "In a smile, you can see one's soul." Well, bright souls are lighting up the landscape everywhere! Whether it is the latest magazine cover or the evening news anchor, a bright, white smile is a very public reflection of America's personality. This helps explain the flood of tooth-whitening products currently in the dental market and why this product segment is projected to grow exponentially.
Tooth-whitening is estimated to represent a billion-dollar, professional-procedure market in 2003. In-office product sales soared 67 percent last year to $100,000,000, not considering the new laser- and arc- lightening systems and prior to the much-advertised television exposure for over-the-counter (OTC) products. Whitening, lightening, bleaching — choose your term — will remain one of the most robust engines driving cosmetic dentistry.
An increase in patient awareness leads to an increase in restorative needs. Patients may come to you for whitening; however, they may need restorative bonding, veneers, or crowns in conjunction with whitening to give them that bright, warm smile. Using a well-educated team approach, whitening as an adjunct can become a very profitable area.
What follows are some of my practice-tested suggestions that might help you reach your comfort level with whitening.
Understanding whitening — patients' wants
Each dental office can improve its case-acceptance rate and outcomes by establishing methods to assess and approach patients with the whitening option that is best for them. The secret to success in dental whitening is best summarized in the familiar phrase, "managing patient expectations." Starting with a clear understanding of patient needs — matched to your office's capabilities — will help ensure everyone's expectations are met.
In my office, I have been successful in determining my patients' needs. Each patient completes an aesthetics questionnaire before the initial exam, which gauges interest in tooth-whitening. One revealing question on my form is, "On a scale of 1 to 10, what do you think about your smile?" It also has become routine for team members to mention whitening in conjunction with restorative treatment, so new crown and bridge work can be as youthful-looking as newly-whitened dentition.
We discuss the patients' response to our bleaching questions to better understand their whitening "want level." That is, are they willing to work at whitening over time (their time at home) or are they a "white-now personality," with little patience for trays and an at-home regime? The former is a potential take-home-kit patient, and the latter will better respond to an accelerated in-office option. We use the "DISC Personality Profile" to help judge what the patient might prefer.
Both you and the patient will benefit from an open discussion of reasonable goals for their existing dentition. What I call "co-diagnosis" — asking questions to determine what patients' expectations are and educating them to choose the proper course of treatment — has worked for me. The whole team approach — from the hygienist to the front-office staff — makes the whitening procedures rewarding and ensures that predictable results are delivered in an efficient manner. Your hygiene staff can be of immeasurable value in educating patients on what can be done.
The time investment you make in presenting your whitening options can range from light to moderate to suit your practice goals. Many take-home options are not overly burdensome to the doctor's time. So, it's easy to understand why these systems remain popular with dental professionals. Plus, at-home whitening procedures may suit certain patients better, due to their predictable shade change. At-home lightening is a more conservative cosmetic procedure, with little or no risk to the tooth/gingivae structure. Though sensitivity and patient compliance are always variables, minimum risk and maximum satisfaction are key attributes of take-home systems.
Average dentist time for at-home systems ranges from 5 to 10 minutes, and support procedures can be standardized. Auxiliary duties (impression-making, tray fabrication, and delivery with instructions) are not complicated. Your clinical assistant is an integral part of the success of take-home systems. She should be comfortable handling any questions or concerns a patient may have, from use of the trays to tooth sensitivity. Normally, a follow-up appointment is scheduled two-to-three weeks post-delivery. This follow-up appointment should be made with the assistant, not the doctor.
Because at-home whitening saves a lot of office chair time, fees to the patient can be kept to a minimum. The fee for this service in my offices ranges from $350 to $400. We also offer a combination program — what we call "boutique services" — that includes the in-office procedure and take-home trays for $775.
Are in-office systems faster, riskier?
In-office whitening systems offer faster whitening through stronger concentrations of active ingredients, ranging from 15 percent to 38 percent of hydrogen peroxide. Some have light/laser "boosting" options to reduce procedure time. Most are two-part, gel-delivery systems, requiring gingival protection (with a dam) and 40 to 50 minutes of chair time with direct dentist involvement. Some of the more popular names in this category are Premier, Discus, DenMat, and Ultradent.
One in-office system not requiring gingival damming is the illuminé™ in-office whitening system from DENTSPLY International. This system offers a 30-percent, H2O2 putty solution that — according to the manufacturer — delivers a minimum of seven shades of lightening performance in 30 minutes.
To better serve the "white-now" patient, the latest evolution of in-office systems includes new methods of acceleration that use light- or laser-bleaching and new formulas. Some of the better known products in this segment include BriteSmile, Biolase LaserSmile, and LumaArch. Available chair time and dental-team supervision are important to be successful with these systems. The companies I mentioned and others have done a great job of marketing to consumers, thus raising the awareness level and the public's interest in bleaching procedures.
Consumer-whitening products have opened the eyes of patients and the door to whitening discussions in your office. Every patient you see has some awareness of the social- and oral-care benefits of a healthy, bright smile. To most dentists' chagrin, patients feel that the whiter their teeth, the better. This is one of the unfortunate outcomes of the barrage of messages consumers receive. But, you can start to control the message — and therefore, the outcome — in your office.
We communicate to our patients about our whitening services from the moment they walk in the door. Several passive methods of appealing to your patients' interest in looking good are easy to implement. Printed materials are the most versatile and cost-effective. They include wall posters, counter stands with "take-one" brochures, and presentation books, all suitable for self-directed review or formal case presentations. Prominently display these materials in clinic operatories, patient-orientation rooms, and reception areas.
Some of the most effective patient materials feature average-looking people with white smiles and few words in the copy. I have found that "before" and "after" photos of your own patients, along with their testimonials, are most effective.
One more point about patients and their testimonials. It's not "news" to you when I say the best referral source is always word-of-mouth from one patient to the other. When your patients give you permission to use procedures you have done on them as subjects for case-presentation materials, they will surely tell their family and friends. Soon, you have more ambassadors for your practice throughout the community.
What white is right?
Each patient is an individual and whitening is important in a complete treatment plan for aesthetic restorative cases. So, you do as much profiling of your patients as possible to sort out their real needs. This is where patient education via passive methods must evolve into more proactive patient-whitening management. Assessing the patient's whitening "want level" and setting appropriate expectations can be done in several ways. Again, the entire dental team is critical in ascertaining this information.
Experts propose that we should bleach until the teeth "match the whites of their eyes." Reaching the desired shade is a subjective assessment, though the benchmark — usually a shade tab — is not. To avoid disappointment as a result of patients' infamous selective memory, try some of these shade-goal procedures:
1. Show a variety of good, realistic results. If you have "before" and "after" pictures of other whitening patients, start with these. Select both mouth close-ups and full-face pictures that allow you to explain to the patient that skin, hair, and eye color are all part of achieving the best overall results, not just a set of refrigerator-white anteriors. If you don't have pictures, use manufacturer's literature until you can implement Step 4 below.
2. Make a team decision — in good light. Make the whitening-shade-goal determination jointly with the patient's input — what I refer to as "co-diagnosis" — using natural light, if possible. If natural light is not available, then use a predictable, preferably color-corrected, light source. Your staff should assist and comment on the shade selected, especially if the patient is asking for unrealistic white results.
3. Don't show the entire shade guide. Control expectations by selecting several white tabs to show your patient as targets that you feel are reachable goals. When patients are shown the entire shade guide, they probably will select the whitest option, regardless of whether it is a realistic or natural goal.
4. Take photographs. "Before" photos. showing the shade-tab target. provide a visual record of the goal. They also serve as a reference for this patient and provide examples you can later utilize to demonstrate typical results for other whitening prospects. "After" photos are useful for future case presentations and for documentation in the patient's file.
Dental team: whitening messengers and monitors
Is every smile in the office as white as it could be? Staff smiles — full of white, healthy teeth — are one of the most critical image-drivers for your practice. The beautiful smiles of your staff not only reinforce the acceptance of the procedures you do, but also crystallize for the staff the importance of the team effort required for a successful whitening protocol.
Mentoring your hygienist to take and record the shade of each hygiene patient's "smile zone" (anterior teeth and even premolars and molars) on his or her chart will give you a benchmark from which future whitening recommendations can be made. In addition, your assistant should observe tooth shade, make the appropriate notations, and initiate treatment discussions.
Finally, front-desk staff should compliment patients on their decisions to enhance their smile and the outcome. When the entire dental team is educated and delivering a consistent message, patients' decisions to whiten their teeth will be continually reinforced.
Sorting out the shades
Since the VITA® Lumin® Vacuum Shade Guide "naturalized" dental-shade selection in the early 1970s, advances in color have been more incremental ... that is, until the "bleaching" phenomenon moved the dental-color spectrum significantly to the left of B1 and A1, to higher- value and lower-chroma levels. Partially as a result of the demand for bleaching, manufacturers are attempting to brand their own bleaching codes as viable color options. Thus, the choice of white-shade options is becoming confusing. Our office found that one of the easiest shade systems to use for coordinating bleaching and restorative procedures is the Illuminé™ white shade guide from DENTSPLY International. This shade guide features eight bleaching shades. All shades are correlated to Ceramco® restorative materials, available from dental laboratories.
The future of bleaching is bright!
Consumers continue to invest in OTC bleaching products at an estimated rate of $1.5 billion per year. What could be your practice's share of this market? Regardless of the answer, the door is open and a bright, white procedure light is shining in!
My practice has found that an open dialogue with the patient to identify needs and set expectations is the most productive way to start a treatment plan that includes bleaching. With a few presentation aids and dental-team coordination, your office can successfully offer this popular cosmetic procedure. I hope that we have helped you decide what it might take to brighten your professional future with whitening.
Your hygienist anchors both the preventive hub and income base of your office. Whitening-procedure management is a natural extension of a hygienist's role as a key dental-team partner and patient manager. What better time than during a recare visit to discuss a patient's tooth color? Two elements need to be addressed to allow more hygiene involvement in whitening:
1. Additional whitening focus time should be included in the hygiene sessions. Now, hold the "My-hygienist-already-tells-me-that-the-allotted hygiene-time-is-too-tight" thought for a second. With appropriate planning, not much extra time is needed. With new patients, you only need three to five minutes for a shade assessment and a short discussion of whitening options as part of any potential restorative work. For existing patient-recare appointments — arguably the most important and frequent contact point — taking one to three minutes for a shade check and chart notation will capture tooth-color degradation. These notes will serve as the basis for a dental team patient-review session and a potential whitening conversation.
2. Team training in whitening assessment and presentation skills, shade-taking, product features and benefits (professional versus over-the-counter), and post-whitening case management is needed. This information is available from manufacturers in-office and through continuing-education or off-site seminars. Much more can be done to integrate this training into a formal whitening protocol.
Why is this so important? "We have periodontal, fresh breath, and restorative protocols," says Kristine Hodsdon, RDH, BS, hygiene lecturer, author, and founder of ReachHygiene. Ms. Hodsdon suggests that "a research-based, clinical-maintenance protocol for whitening would clear up much of this confusion and be a distinguishing factor for the profession and for the manufacturer leading the effort."