Whitening — Tooth-whitening is in!
Lou Graham, DDS
Over the past 20 years, many incredible
breakthroughs have been made in dentistry. These changes have enabled
dentists to offer their patients a multitude of treatments in
orthodontics, periodontics, implantology, and especially restorative
dentistry. People are living longer, putting a greater emphasis on how we
as providers can preserve their dentitions in the most conservative
manner. Adhesion dentistry is one way we can do this. Advancements in
direct and indirect bonding have given dentists the opportunities to
utilize more conservative preparations and thus preserve essential tooth
Bleaching is another aspect of conservative dentistry. There is no
question that, in the United States, "white is in" and every product line
and advertisement reflect it. The value of a smile has simply boomed, and
the most conservative procedure a dentist can provide is bleaching. This
article will review the diagnostic approaches, the value of the team, and
how bleaching can be the first step in rejuvenating a patient's smile.
The first opportunity to understand the needs of new patients occurs when
they call the office for their initial appointment. A well-trained,
front-office coordinator can promote the quality of the office and, more
importantly, welcome, inform, and get to know patients and their
The initial call is crucial to a practice's success ... and it often is
the most unappreciated aspect within the office! The information gathered
from this call can be discussed at the office's morning huddle prior to
the patient's appointment, allowing the staff to have an early
understanding of the new patient. This gives patients the wonderful
feeling of a personal "hello" versus simply filling out forms in a foreign
The initial forms can provide a plethora of knowledge for the dentist as
he or she meets the patient for the first time. Questions asked on our
* Are you happy with your smile?
* If not, what would you like to improve?
* Do you want to keep your teeth throughout your life?
These questions allow the dentist to gain an understanding of patients'
interest in aesthetic dentistry and to determine how important it is to
them to preserve their dentition. Even if patients are happy with their
smiles, the dentist still can review the correctness of occlusion and the
color of the teeth, as well as discuss various oral-health needs. It is
critical that the initial appointment not be a sales appointment (as too
many are), but one in which the patient and doctor establish a
relationship with each other. This one point is the key to success for
many practitioners and the reason for failure for others.
One approach I follow is to discuss my own values and philosophies of
treatment with the patient. Generally, the vast majority of our patients
are referred to the practice. This only reaffirms that our message has
been received by the referring patients who have come to trust us. This
discussion of values and philosophies usually takes place after listening
to a new patient and taking a complete medical and dental history. This
should all be done prior to ever opening your patient's mouth!
Our philosophy in our approach to patient care is to always be as
conservative as possible. This can translate into orthodontics versus
veneers, early laser caries detection, pulp-capping symptom-free teeth
with carious exposures (we have a high three-year success rate), and
nonsurgical periodontal therapies. This does not mean we do not do veneer
smiles; but, if patients wish to undergo orthodontics and have beautiful
natural teeth afterwards, this is ultimately the most conservative
long-term treatment possible. Obviously, many combinations of treatment
may be needed, which only reinforces the importance of understanding the
individual needs of your patient. Thus, the keys to that first visit are
listening, sharing, and offering a variety of treatments best- suited for
that particular patient.
There is no treatment more conservative than bleaching in restoring teeth
to a brighter hue, while preserving enamel. We generally discuss bleaching
at most initial or consultation appointments. In this discussion, we
analyze the patient's smile, the shape, color, and proportions of their
teeth; their alignment, occlusion, and parafunctional issues. Teeth that
are in the "A" and "B" shade ranges are the easiest to change, while those
in the "C" range are more difficult. Teeth that have varied hues, chromas,
and enamel/dentinal staining are certainly more challenging to whiten, and
this must be addressed at the outset. The patient must have realistic
expectations, and the dentist must hear the patient.
At this time, we talk about the various options that the patient can
consider, understanding the personality type (A, I, P, and S), and then
bringing it all together. We always discuss noninvasive treatment if it is
possible. Veneers can always be done, but once that enamel is gone, it's
gone! How long can those beautiful veneers last? Is 10 to 15 years of
success acceptable to the patient? Do patients understand that ultimate
retreatment is very likely (years later) and there always are risks versus
This author truly understands the value of restoring a new smile with
ceramic veneers to a patient with numerous worn and discolored
restorations or with severe tetracycline-stained teeth, yet, simply
brightening an A1 shade to a brighter shade and correcting a small
diastema are not proper indications. An investment of $400 for
tray-bleaching or $700 for power bleaching and trays (the patient will
need trays in most cases) is relatively a "giveaway" versus 6 to 16
veneers. These findings and realistic expectations only reinforce your
patient's trust in you.
Frequently, bleaching is the first step to aesthetic enhancement.
Pre-existing crowns and restorations must be addressed prior to any
bleaching, and a full treatment plan is essential. Orthodontic treatment
often follows once patients see the dramatic improvement in the color of
their teeth. Passive tooth eruption with discolored teeth is another issue
that should be addressed prior to bleaching treatment. Analyzing proper
tooth dimensions is an important part of the initial exam, and discolored
short teeth with excess gingival tissue should be periodontally treated
prior to any bleaching procedure. Patient habits — such as smoking,
drinking tea, coffee and/or red wine, and numerous other issues — are all
identified and discussed prior to commencing treatment. This lets patients
know that they may require longer treatment or more frequent touch-ups
because of their daily habits. This is why smile analysis should be a part
of an overall comprehensive exam. A subsequent treatment plan is essential
to long-term patient/doctor relationships.
Patients who want multiple-color changes at the first appointment can be
offered numerous bleaching options. Diode lasers, BriteSmile®, Zoom®,
Luminare, and other products offer initial dramatic improvement in most
cases. These in-office procedures often require one-to-two hours for both
arches. Offices that have available operatories and well-trained
auxiliaries can make these treatments profitable. All require gingival
dams for protection. Patients must be warned about acute sensitivity of
the teeth for one-to-seven days following treatment. Patients also should
be told that "rebounding" can occur over time and that follow-up will be
needed with strips or bleaching trays (our preference). Patients with
personalities that are very driven are the best candidates for such
For offices with a lack of space and time, trays deliver the same results
with five-to-seven days of use. The use of chair time in our smaller
practice for bleaching one- to-two hour a few days per week would
interfere with our present patient load. Those patients who request power
bleaching are simply referred to our other office (or to colleagues in
other locations) who have well-trained staff and available chair space. It
has been our experience that power bleaching does give that initial "wow,"
yet the majority of our patients who utilize the tray system feel the same
Sensitivity issues are discussed at each appointment. Patients who have
recession and erosion in the cervical areas often have severe sensitivity
issues, and this may be a contraindication to bleaching. We've had good
success with patients alternating sodium fluoride treatments with 10-to-15
percent carbamide peroxide. Patients who truly have pre-operative
sensitivity are first given a Q-tip with a bleaching gel, and if the
sensitivity is unfavorable, we choose another direction for initial
treatment. Gingival grafting is one alternative, and placement of Class 5
restorations (estimate the future color) can be another. The key is
diagnosis first, and the best treatment path will follow.
The value of our assistants in the process is immeasurable. They not only
take the impressions and fabricate the trays, but reinforce the patient's
decision and review all the post-operative instructions. Patients who have
questions after leaving the office frequently call the assistant for
answers, leading to a very positive relationship. Another key player in
cosmetic dentistry is the hygienist. More often than not, long-term
patients establish excellent relationships with their hygienists. As the
patient's aesthetic needs change, the hygienist can be an excellent
partner in discussing cosmetic dentistry. The diagnostic and clinical
skills of hygienists are changing as we write this article. A successful
cosmetic- dentistry office must include a well-trained hygiene team.
There is no denying that patients of all ages desire to look better.
Improving their smiles can be a major part of an improved appearance.
Understanding your patient's wants and needs, coupled with a thorough
initial exam, can help them achieve their aesthetic goals. No other
procedure can treat a patient's smile in such a reversible manner and give
such positive results as bleaching. It will continue to be a successful
tool in our armamentarium for improving our patients' smiles. With baby
boomers aging — and Bo-Tox injections in the hygiene chair not a distant
thought — keep those bleaching refills stocked!
This article originally appeared in Dental Economics June, 2003
Author(s) : Lou Graham