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 structure.

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 priorities.

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 environment.

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 forms include:

* 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 rewards?

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 treatments.

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 away.

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