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Dental practices have always evaluated and recommended products, either directly or indirectly. The choice of one product over another during treatment or the inclusion of specific products in the “goody bag” sends a powerful signal to patients. In addition, there are other highly visible products dispensed in the office to support therapeutic treatments and prevent or counter side effects such as sensitivity.
Patients generally appreciate the convenience of being able to purchase products at the time of treatment and often seek that same level of confidence by asking about and purchasing other oral healthcare products advertised in consumer media or seen in stores. This is supported by dental manufacturers’ findings that practitioners’ recommendation can substantially impact consumers’ decision to buy a particular oral health product.1
Support for the Concept of Recommending Products
There are many good reasons for dentists to express their confidence in particular products. With so much highly publicized oral health “information,” it can be difficult for consumers to determine the accuracy of the claims and the credibility of their sources.2 H owever in contrast to the methods and motivations of the marketplace, society expects more from dentists:2 T his is supported by a 1994 ADA survey in which Americans said they relied most on their dentists for dental information.3
As Schechter observes, patients often turn to their dental office staff with their questions about the accuracy of oral health information encountered through the media. They want to know how they can best prevent or treat periodontal disease, as well as to determine the best of the many home care products for teeth whitening, halitosis, and caries.4
Ozar says dentists should make it their business to educate patients, to become well-versed about these options themselves, so they in turn can be “articulate educators of your patients about what dental professionalism really means for them and why meeting these challenges to dental professionalism is important not just for dentistry, but for all people.2
According to Schechter, professionalism demands that dentists reverse their belief that it is not only appropriate to recommend products but also dispense them in their offices. “If done properly, this results in a true win/win situation,” he writes, adding that patients find it convenient to purchase home-care products at their appointments, where an additional benefit is that they are instructed on how to use those products properly, and can begin using them immediately. The office staff, too, can take comfort in knowing patients have the right products for their home case and know how to use them.4 I n fact, he adds, some people deliberately choose offices where certain products are sold, believing practices that offer high-quality home-care products also provide high-quality dentistry.4
The ADA Position
The American Dental Association (ADA) recognizes the value patients place upon their dentists’ recommendations. Its Report and Advisory Opinion of the Council on Ethics, Bylaws and Judicial Affairs on the marketing or sale of products or procedures states, “No one knows more about oral health care or is better qualified than the dentist to make recommendations about the safety and efficacy of dental products. Indeed, patients look to their dentists for this kind of advice.”5
However, that report does note the potential for a conflict of interest and makes it clear that dentists who promote or sell specific products should do so with their patients’ best interests in mind and in compliance with professional expectations, including that they follow “high ethical standards which have the benefit of the patient as their primary goal” and in keeping with the principle of veracity, ie, “the concept that professionals have a duty to be honest and trustworthy in their dealings with people.”5
The ADA also notes that “auxiliaries under the dentist’s supervision should not be permitted to recommend treatment until the dentist has examined the patient and determined that the treatment is appropriate” and that “dentists should not induce their patients to purchase products or undergo procedures by misrepresenting the product’s value, the necessity of the procedure or the dentist’s professional expertise in recommending the product or procedure.”5
For health-related products, the ADA position holds that dentists not rely solely on the claims of manufacturers or distributors about the safety and efficacy of products, but that they themselves have “an independent obligation to inquire into the truth and accuracy of such claims and verify that they are founded on accepted scientific knowledge or research.”5
Safety and efficacy criteria are defined for oral products by the American Dental Association’s Council on Scientific Affairs in both its Acceptance Program Guidelines for Home-Use Tooth Stain Removal Products,6 and Over the Counter Home-Use Tooth Stain Removal Products.7
The ADA does, in fact, model this obligation through the creation and promotion of its American Dental Association Seal of Acceptance, verifying that products have been “objectively evaluated for safety and effectiveness by an independent body of scientific experts, the ADA Council on Scientific Affairs.” The products, a complete list of which can be found as a “shopping list,” include items “cleared by the U.S. Food and Drug Administration for market directly to consumers, regardless of whether the company elects to market the products over-the-counter or exclusively through oral health care professionals.” It includes “therapeutic agents, drugs, chemicals, materials, instruments, and equipment that are employed in the treatment or prevention of dental disease.”8
In addition, the ADA recently announced the launch of its new Dental Product Guide e-pub that will provide news and information on a wide range of dental products. According to the ADA News, the epub also will include brief reports from ADA-member dentists showing step by step how they use selected dental products in their own practices and explaining “how the designated products helped them respond to specific patient needs and concerns, leading to successful outcomes and positive patient experiences.”9
Evaluating and Selecting Products
With ADA-espoused tenets in mind, dentists should recommend and sell only products they believe in by companies they trust. However, the greatest challenge to them, according to Ozar remains “giving proper priority to patients’ well-being and building ethically correct decision-making relationships with patients while, at the same time, trying to maintain a successful business operation.”2
Practices that wish to dispense products should consider those that improve at-home oral health care for patients, including proven toothbrushes, rinses, water flossers, etc, as well as refills of products used previously. In all cases, the patient can be instructed on proper usage and duration of treatment, and the dentists can ensure that the products provided are compatible with those used at home.
Periodontal Health Maintenance Products
Products provided professionally for periodontal health maintenance include high-quality antimicrobial rinses such as chlorhexidine gluconate 12% or alcohol-free rinses with essential oils and herbal extracts. Other professional products are useful for both periodontal disease and malodor. The office can also dispense hand-held syringes, pocket irrigators, mechanical irrigators, and solutions for use with these devices.4
Quality of Life Products
In addition to the positive effect they have on a practice, products that give people fresher breath or whiter teeth contribute to their quality of life and are in great demand
Whitening
For patients who have been appropriately screened in the office, whitening products can be used to whiten or maintain whitening previously achieved through at-home or in-office treatment. It is in the best interests of patients who wish to whiten their teeth to purchase a home-bleaching kit from their own dental practice, which can provide the appropriate strength for the individual as well as custom-fabricated, properly contoured and trimmed custom trays and instructions on proper usage.4
Breath Freshening
Breath products are another area of confusion. Products include mouthrinses, tongue cleaners, gums, and mints. Even the four rinses most commonly prescribed by practitioners vary greatly in their formulations, which are based on 1) essential oils and organic herbal extracts; 2) stabilized chlorine dioxide and zinc acetate; 3) a compound of zinc chloride, thymol, and eucalyptus oil; or 4) 3% carbamide peroxide. As for the tongue cleaners, not every one is appropriate or effective for every situation.4
Some additional products such as mints, gums, and mouthrinses have breath freshening or whitening effects, as noted below in the literature. The dentist can determine which is most appropriate among these professionally available products.
Ensuring Product Efficacy
In keeping with the ADA position that dentists should verify that products they recommend or dispense are based on valid findings, there are numerous reports in the literature that support the quality of professionally dispensed dental products compared to over-the-counter options.
Rinses and Scrapers for Malodor
Halitosis may affect up to 30% of the population worldwide. Its management is directed at controlling and reducing the bacterial load both in periodontitis and in tongue coatings by instituting proper oral hygiene measures, control of tongue flora by brushing or scraping, and possibly the adjunctive use of antiseptic agents.10 W hile the vast majority of cases (80% to 90%) of this common condition originate in the oral cavity due to gingival pathologies, caries, and poor oral hygiene, the remainder arise from behavior such as diet choices, alcohol abuse, tobacco smoking, drugs, along with diseases of other parts of digestive tract as well as some systemic conditions.11 F or that reason, it is important to determine the cause of oral malodor before recommending treatment, which may include a variety of rinses, tongue scrapers, and other approaches described in studies.
A study reported by Malotra and Yeltiwar determined that, while both essential oil and chlorhexidine mouthrinses have antimicrobial properties and are effective, chlorhexidine is more so.12 H owever, as Rostoka and others point out, while mouth rinsing agents with essential oils ensure the renewal of a normal microbiota in the oral cavity, decrease the quantitative amount of bacteria and products released by proteolytic bacteria, and possess a typical antimicrobial activity, they do not form resistant microorganism strains or cause allergic reactions.13
Investigators reviewing two databases to compare tongue scraping with other interventions (including mouthwashes and toothbrushes) to reduce mouth odor in adults with halitosis found “no high level evidence” in support of mechanical over other forms of tongue cleaning.14
A study by Nohno and others presented an alternative to mechanical removal of tongue coat believed to cause malodor. It sought to determine the effect of long-term use of candy tablets containing protease, actinidine, on both on TC accumulation and concentration of volatile sulfur compounds (VSCs) in mouth air. The results of the study suggest that the tablets containing actinidine had an accumulative effect in reducing VSC in mouth air with long-term use.15
Whitening
Numerous recent studies attest to the effectiveness of various tooth-whitening systems. Matis et al reviewed nine published studies evaluating 25 products in four different systems, and tooth whitening was observable with all methods of bleaching. Dentist-prescribed overnight bleaching was shown to be the most effective method of bleaching.16 L ikewise a study by Rowan and others determined that dentist-prescribed overnight bleaching is more effective than over-the-counter methods for vital tooth bleaching.17
In addition, there are other types of whitening products—including rinses, gums, and mints available from practitioners. Among them, investigators reported that two prescription chewing gums used for nicotine replacement therapy in an in vitro study using bovine incisors were found to be more effective for tooth stain removal than a whitening gum and saliva.18 Another study, a controlled 12-week single-blind trial clinical study involving 27 smokers and 27 nonsmokers, assessed the effect of a chewing gum containing sodium hexametaphosphate (4%) on the inhibition of stain formation and found that it reduced induced stain formation by 33% compared to a no-gum treatment.19
Method of Dispensing
In-office dispensing is a convenience for patients because they can immediately purchase treatment-related products and be instructed in their proper usage while they are in the office. However, online dispensing is becoming increasingly popular both among practitioners who want to offer their patients a greater variety of products and patients who are accustomed to online ordering and may find it inconvenient to return to the office to repurchase previously prescribed therapeutic products. Patients may especially appreciate the opportunity to more privately and conveniently purchase quality of life related products such as whitening and breath products.
Online Dental Product Shopping
Most patients are familiar with e-commerce used to purchase goods and services online. Dentists who wish to enter this arena have a number of choices, including installing an e-commerce component to their business, implementing an e-business software system that also integrates with accounting, customer relationship management and inventory management; or outsourcing it entirely either to a provider that enables them to select products from a variety of manufacturers or a single trusted manufacturer that provides and supports high-quality products. In this last model, the oral product manufacturer typically creates for the dental practice its own personalized web store to which it can refer patients, conveniently generating incremental profits for the practice while improving patient access to professional whitening and oral care products—eg, re-filled whitening trays; whitening toothpaste, gum, mints, and touch up brushes; and probiotic mints. The company manages the website and the inventory for the practice, which receives a portion of the profit from product sales generated through the practice’s website. It processes patient credit card payments and fulfills all online orders on behalf of the practice by shipping directly to the patient.
As observed by Grieb, e-commerce is changing the dynamics of patient, doctor, and manufacturer relationships in that there is increased interaction between patients—who are assuming more responsibility for their choices—and their physicians as they educate each other in an effort to arrive at mutual decisions.”20 A t the same time, in response to these better-informed consumers, manufacturers must establish the credibility of their products. “These new dynamics have resulted in a trend towards mass customization, which involves tailoring products to patient variability in efficacy and side effects.” He also notes a trend toward two-way communication in which manufacturers who are in direct contact with customers are learning more about their individual needs and are therefore poised “to maximize outcome benefits by offering a full range of products, services, and information in a personalized and vertically integrated online store.”20
Conclusion
Because their patients depend on them as trusted sources of advice and information, practitioners can and should offer patients the many advantages of recommending and supplying products that support therapeutic and esthetic goals, including unfamiliar products that may meet their needs or esthetic goals—eg, whitening products, sensitivity products, breath fresheners, etc.
The key is in doing it ethically and responsibly with patient care uppermost in mind and promoting only safe and effective products with which they are familiar, in keeping with ADA-espoused guidelines for ethical and appropriate conduct.
Doctors can do this from their offices, but increasingly they are choosing to create online stores to accommodate digitally savvy patients where they “live” and are likely to shop at all hours of the day.
References
1. American Dental Association. Survey on Dental Health Care Issues. November 1994.
2. Ozar DT. Professionalism: Challenges for dentistry in the future . BMC Oral Health. 2006; 6(Suppl 1): S6.
3. Schwartz, DM . Should selling products be a part of your practice? Dental Management. 1989:29(1);28-37.
4. Schechter B. Selling home care. Dental Economics. http://www.dentaleconomics.com/articles/print/volume-90/issue-8/features/selling-home-care.html. Accessed April 16, 2013
5. ADA. Report and Advisory Opinion of the ADA Council on Ethics, Bylaws and Judicial Affairs on Advisory Opinion 5.D.2. MARKETING OR SALE OF PRODUCTS AND PROCEDURES (PDF) http://www.ada.org/files/Final_Report_on_Adv_Op_5_D_2_7-28-99-S.pdf. Accessed April 9, 2013.
6. ADA Council on Scientific Affairs. Acceptance Program Guidelines: Home-Use Tooth Stain Removal Products, 2012. http://www.ada.org/sections/scienceAndResearch/pdfs/guide_home_stain.pdf. Accessed April 9, 2013.
7. Guidelines for Over the Counter Home-Use Tooth Stain Removal Products, 2006. http://www.ada.org/files/guide_overcounter_bleach.pdf. Accessed April 19, 2013.
8. ADA Seal of Acceptance. http://www.ada.org/ada/seal/shoppinglist.aspx
9. ADA News. Dental Product Guide. http://www.ada.org/productguide.aspx. Accessed April 19, 2013.
10. Hughes FJ, McNab R. Oral malodour--a review . Arch Oral Biol. 2008;53 Suppl 1:S1-7.
11. Zalewska A, Zatoński M, Jabłonka-Strom A, Paradowska A, Kawala B, Litwin AHalitosis--a common medical and social problem. A review on pathology, diagnosis and treatment . Acta Gastroenterol Belg. 2012 Sep;75(3):300-309.
12. Malhotra S, Yeltiwar RK. Evaluation of two mouth rinses in reduction of oral malodor using a spectrophotometric technique . J Indian Soc Periodontol. 2011; 15(3): 250–254.
13. Rostoka D, Kroiča J, Iriste V, Reinis A, Kuznetsova V, Teibe U. [Treatment of halitosis with mouth rinsing agents containing essential oils].[Article in Russian] . Stomatologiia (Mosk). 2012;91(3):27-34.
14. Outhouse TL, Al-Alawi R, Fedorowicz Z, James V Keenan JV. Tongue scraping for treating halitosis. Editorial Group: Cochrane Oral Health Group. Published Online: 8 OCT 2008.
15. Nohno K, Yamaga T, Kaneko N, Miyazaki H. Tablets containing a cysteine protease, actinidine, reduce oral malodor: a crossover study . J Breath Res. 2012;6(1): 1752-1755.
16. Matis BA, Cochran MA, Eckert G. Review of the effectiveness of various tooth whitening systems . Oper Dent. 2009;34(2):230-235.
17. Rowan S, Forney A, Gureckis K . Dentist-prescribed overnight bleaching is more effective than over-the-counter methods for vital tooth bleaching Tex Dent J. 2012; 129(8):772.
18. Moore M, Hasler-Nguyen N, Saroea G. In vitro tooth whitening effect of two medicated chewing gums compared to a whitening gum and saliva . BMC Oral Health. 2008;11;8:23.
19. Porciani PF, Grandini S, Perra C, Grandini R.Whitening effect by stain inhibition from a chewing gum with sodium hexametaphosphate . J Clin Dent. 2006;17(1):14-16.
20. Grieb J. Summer Seminar: E-Commerce in Health Care . Health Policy Newsletter Vol. 14, Number 3 (September 2001), Article 4.