The many shades of whitening

There are few, if any, dental treatment modalities that have captured the interest and acceptance of the dental patient like teeth whitening.

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Th 184737
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There are few, if any, dental treatment modalities that have captured the interest and acceptance of the dental patient like teeth whitening. White teeth are universally desired throughout the industrialized world. This desire - combined with the ability of the average dentist to deliver a conservative, inexpensive, safe and highly effective method to satisfy this public desire - has resulted in the explosive growth of not only teeth whitening, but cosmetic dentistry in general. In other words, a white smile is the universal public itch and carbamide peroxide/hydrogen peroxide is the universal public cure. Whitening, more than any other single dental procedure, has enhanced the public image of the dental profession. At the same time, it has provided the public with an overwhelming reason to seek dental services.

Because whitening is so effective and so apparent to both a patient and his or her social circle, it has been my experience that the potential for a patient’s word-of-mouth referrals is higher for bleaching than any other patient category.

Should a practice offer teeth-whitening services? When the above paragraphs sink in, I think it should be abundantly clear that every dental practice in this country can benefit by offering teeth whitening. In this article, I will discuss how whitening is optimally utilized in the contemporary dental practice and the profound effect that this treatment modality can have on every aspect of a practice.

First, though, let me provide a review of the most salient points about dental whitening or bleaching:

1)It works for everyone.

2)Studies demonstrate that hydrogen peroxide - the active ingredient and the breakdown product of carbamide peroxide - passes through enamel, dentin and pulpal tissue and the opposite side of the tooth. Thus, it is effective for tetracycline staining. But it needs to be utilized for several months, rather than several days, as in nontetracycline stained teeth.

3)Carbamide peroxide/hydrogen peroxide does not have any known permanent deleterious effects on enamel, dentin, or pulpal tissue. Thus, pulpal and gingival irritations are always reversible.

4)The degree of whitening is dependent on the concentration of the bleach and the amount of time the bleach is in contact with the teeth. Because of this, bleaching trays are the best choice when the whitest possible shade is desired, or when tetracycline staining is present. In office bleaching modalities such as BriteSmile, Rembrandt and Zoom are desirable to patients, nonetheless, because of their ease of treatment. Patients also may utilize both techniques - in office bleaching for expedient whitening and take home trays for additional whitening and maintenance.

5)Follow-up whitening procedures are necessary as whitened teeth are not impervious to future staining.

6)Whitening procedures are highly profitable. Bleaching materials are inexpensive and bleaching procedures can be performed by well-trained auxiliary staff in most, if not all, states.

7)Always take a preoperative shade as patients can easily forget the appearance of their teeth before bleaching.

The initiation of the discussion on esthetic enhancement of a patient’s teeth should be the responsibility of the dentist, not the patient. I think the belief by dentists that only the patient should bring up the subject of cosmetic procedures should be abandoned immediately. Patients expect their dentist to be an expert in the understanding of cosmetic dentistry and, thus, in a position to discuss the candidacy of each patient for whitening procedures. I believe a patient feels that a dental examination is incomplete, or of low quality, if it does not include a discussion of his or her esthetic condition and esthetic treatment options. This is true even if a patient does not broach the subject of cosmetic dentistry.

I have found the following protocol for esthetic consultation to be informative to the patient, time-efficient for the doctor and image enhancing for the dental practice.

Educating the patient to the point that he or she might seek whitening services begins at the first appointment, during the initial oral examination. In fact, the first question that I ask every new patient is, “How may I be of the most service to you?” If the patient indicates an interest in esthetic enhancement, I immediately ask what he or she would change. The answer to this important question will always include whiter teeth. Straighter, less-worn incisal edges, altered-tooth contours and resolution of crowding are less frequently mentioned.

I always discuss whitening initially with a patient. This discussion will include the different methods of whitening (take home trays vs. in office bleaching), expected results, whitening’s well-documented safety, fees and the promise that it works for everyone’s natural tooth structure. At this point, I usually do not discuss orthodontics, porcelain veneers, or crowns. I need to complete a clinical and radiographic examination in order to discuss these subjects intelligently with a patient.

At this juncture, a discussion of the psyche of the consumer/buyer in general and the psyche of the dental patient specifically should take place. First, a new patient does trust you, the dentist, to some degree. After all, the patient has - of his or her own free will - chosen to come to your office above all others. Second, this patient desires whiter teeth. I am sure of this because I have asked the last 2,000 new patients if they would like to change anything regarding their smile. All of them said that they would like whiter teeth. Third, you can assume that the patient already has a fundamental understanding of teeth whitening and knows someone who has benefited from it. Fourth, most patients, at least those in the New England area, do not wish to appear vain or self-conscious. As such, they may feel uncomfortable initiating the discussion of cosmetic dentistry or whitening. Many of my patients, especially men, seem relieved when I initiate the subject of the appearance of their teeth.

From a patient-management standpoint, the subject of teeth whitening is a perfect starting point for dialogue with the patient on additional esthetic treatment modalities such as orthodontics, porcelain veneers, posterior composite restorations, enamel recontouring and crowns. Indeed, many of the more elaborate esthetic cases that I have completed actually began with a simple discussion of teeth whitening. The important point is that initiating a discussion on esthetics about a treatment that the patient desires anyway - bleaching - allows a dialogue for other esthetic treatments to take place in a relaxed fashion. Once whitening procedures have been completed, patients - in general - become committed to other esthetic procedures such as posterior composites, replacement of old ceramometal crowns with metallic marginal displays and orthodontics.

In a perfect world, every patient who desires whiter teeth would accomplish this prior to the placing of any crowns. Sometimes, however, due to more pressing dental restorative needs and/or the patient’s financial limitations, I must complete various posterior crowns prior to whitening the natural teeth. In these cases, I simply suggest to the patients that they allow me to select a porcelain shade that is whiter than the present color of their teeth in anticipation of later completing whitening procedures. Nearly every patient accepts and thanks me for this suggestion. Additionally, these whiter crowns provide a constant reminder and motivator for patients to complete the whitening phase of their treatment.

Finally, but of paramount importance, is the impact that offering whitening and other cosmetic treatment choices can have on your practice’s image. It is difficult to imagine any patient would think that a dental practice which does not offer at least teeth whitening is modern, up-to-date, professional and therefore able to perform high-quality dental care. Sending the patient to the supermarket to purchase an over-the-counter whitening system reflects poorly on the practice’s level of sophistication. It also sends a message to a patient that a dentist simply does not care about the patient’s needs, but rather only those needs that are important to the doctor. If cost is the reason for recommending an over-the-counter product, a patient and the dentist would benefit from knowing that these products contain a lower concentration of bleach. Therefore, over-the-counter products require more applications, more of a patient’s time and a higher cost to achieve the same result as doctor-directed bleaching procedures.

In summary, whiter teeth are desired by everyone - even if they do not admit it readily. Dentists can provide whitening procedures safely, effectively, inexpensively and profitably. Whitening promotes a myriad of additional dental procedures that enhance a patient’s appearance and oral health. Offering whitening as a patient service reflects positively on every aspect of a practice. There is no more powerful referral source than a patient whose treatment by a dentist was painless, inexpensive and which dramatically enhanced the patient’s appearance and self-image.

Dr. George Salem maintains a private, fee-for-service dental practice in Braintree, Mass. Founded in 1989, the practice has grown into a multispecialty group office that employs periodontal, orthodontic, and oral surgical specialists. The practice provides management of dental patients with simple to highly complex reconstructive and cosmetic needs. He is a Fellow of the Academy of General Dentistry, and author on practice management, patient management, and prosthetic techniques. He is also the inventor and original patent holder of the Kerr OptiClean® dental bur. Contact Dr. Salem by e-mail at

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