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As highly trusted healthcare providers, dentists must carefully consider how the products and services offered in their practices serve the best interests of their patients and reflect upon them as practitioners. This is particularly the case with options geared toward patients’ “wants” rather than “needs.” However, for a growing number of dentists, the financial survival of their practices requires that they make a greater effort to address economic realities without compromising patient care. One way doctors can generate additional revenue while responding to their patients’ desire for smile enhancement is to offer safe and effective tooth whitening products and services in the office.
A Whole New World of Dentistry
By all accounts, the world of dentistry as it once existed has changed. An earlier generation of dental students emerged from training to launch careers that were soon providing professional satisfaction and a comfortable lifestyle. However, in recent years, a severe recession, whose effects continue to strain patients’ budget, coupled with the impact of technology on how people identify and purchase products and services, has forever changed the business models of those who provide those products and services, including healthcare professionals.
Dentists—especially new grads—are further impacted by what dental practice management consultant Roger Levin calls “permanent game changers,” including higher dental school debt, lower insurance reimbursements, and steep competition, not only from new players such as dental service organizations, but also “old players”—ie, practicing dentists who are delaying retirement for an average of 8 to 10 years to recover income lost due to these forces.1
This income reduction has been a rude awakening for private practice dentists, who had remained relatively unscathed even during the depth of the recession. A Forbes article traces the change in fortunes to 2011, when profits in private dentist offices were down 3% after posting what the article described as “ongoing, though shrinking, gains in their top lines throughout the recent recession.”2
In light of these realties, is it now clear that for practices to not just survive, but thrive, in this very different economic climate, they must change the way they do business—perhaps first of all by recognizing that a dental practice is a business and requires initiatives in keeping with that reality.
Taking the Initiative
Perhaps for the first time in the history of the profession, dentists—both in new and long-established practices—can no longer expect patients to come to them; they must be proactive. Dentists need to identify opportunities to increase production both by attracting new patients and providing more dentistry to the patients they already have. They need to make patients aware of what they have to offer—eg, a reputation for excellence, modern technology, special services—and must otherwise set themselves apart from their competition. Practice marketing using all forms of media, including social networking, is now considered a necessity in many practices to attract new patients and to provide information about appointments and special services for existing patients.3
What Patients Want
Dentists who offer patients the products and services they want as well as those they need—in keeping with their professional knowledge and their patients’ trust—stand to profit financially.
One of the things patient want is whitening. Given the opportunity, a significant proportion of the patient population—particularly patients who are esthetically inclined—would choose to have whiter teeth. This is borne out by an American Academy of Cosmetic Dentistry survey in which the most common response to the question “What would you like to improve most about your smile?” was: Whiter and brighter teeth.4 This desire was corroborated by a 2004 USA Today survey on the services patients want; an overwhelming majority (85%) chose teeth whitening.5
Given their patients’ interest, dentists can leverage their professional knowledge and credibility by establishing themselves as a resource for patients who desire tooth whitening. In this way, doctors who offer their patients the whitening options/products they desire can build their practices by providing these products/services ethically and in keeping with the patients’ best interests. An added benefit is that they can thus identify cosmetically minded patients who may desire other esthetic services provided by the practice.
What Patients Need
Serving as a whitening resource is good medicine as well as good business. Dentists have the education and training to make sure patients’ health needs are being served as well as their esthetic desires. This is supported by a whitepaper published by the ADA Council on Scientific Affairs, which maintains, “Tooth whitening is best performed under the care of a dental professional.”6
As suggested by the above-referenced ADA whitepaper, there are many reasons dentists should be the “first responder” to this patient “want.” First of all, teeth can be discolored for many different reasons, including underlying illness that requires medical treatment; and not all patients are good candidates for bleaching methods due to issues such as sensitivity or staining that is resistant to bleaching.6
Dentist can screen potential bleaching candidates based on their knowledge, the patient history, and special testing methods. They can thus determine the best approaches for the individual patient, offering products and procedures to treat/prevent side effects likely to occur in combination with effective whitening methods. Patient unlikely to experience side effects may benefit from use of the strongest available bleaching agents.7
For patients who prefer at-home bleaching solutions—either for economic reasons or convenience—the dental team can recommend and provide individual products that specifically target those patients’ needs—including dentist-dispensed and OTC products.7
In any case, the ADA urges all patients—even those considering OTC bleaching products—to see their dentists before proceeding. This is especially important for those with extensive restorations and very dark stains.6
Steps to Take
Identifying Potential Whitening Patients
There are numerous ways to identify potential whitening patients during the course of a new patient visit or recall visit. This information can be included on a questionnaire or elicited during the medical history interview. This exchange need not be handled by the clinician. Patients respond to education from the entire dental team. Dental assistants, hygienists, and office managers are primary drivers of patient communication.
Patients can also be made aware of their dental team’s whitening expertise and available services through product displays, website information, and manufacturer-provided materials and information.
Conducting Patient Evaluation
According to the American Dental Association Statement on the Safety and Effectiveness of Tooth Whitening Products, which was adopted by the Council on Scientific Affairs in 2012, “A thorough oral examination, performed by a licensed dentist, is essential to determine if bleaching is an appropriate course of treatment. The dentist and patient together can determine the most appropriate treatment. The dentist may then advise the patient and supervise the use of bleaching agents within the context of a comprehensive, appropriately sequenced treatment plan.”7
Therefore, patients who express an interest in whitening should be scheduled for an evaluation during which the dental team can determine the following: the source of the discoloration; the likelihood that the patient will experience side effects such as sensitivity; and the likelihood that the patient will respond to treatment.8
This visit should include a clinical evaluation for caries, oral tissue injuries, active gingivitis or periodontal disease, tooth sensitivity, and new or faulty restorations; it may also include a radiograph for evidence of pulpal necrosis.8,9
Patients should also be assessed at this time for contraindications to successful outcomes including allergies to materials, tooth sensitivity, willingness and ability to follow treatment, costs, and expectations.8
After the evaluation, it is important to inform patients about issues that could impact their whitening treatment. For example, anterior decay, class V abrasions/abfractions, and cracked teeth can cause long-term sensitivity if left untreated prior to whitening.5
Patients who decide to pursue OTC treatments other than those offered by their practitioners on their own should be cautioned to carefully read instructions and warnings and to call the dental office if they experience adverse events including tooth sensitivity that was not present before, over-whitening, gingival damage, etc.10
Treatment Planning
Among patients cleared for whitening, treatment planning involves not only selecting the most appropriate method from those listed below, but also determining whether other treatments should be performed prior to or in conjunction with the whitening procedure to improve esthetics or minimize side effects. For example, patients should be screened for sensitivity, and if it occurs, be offered treatments such as with 5% potassium nitrate with fluoride. In addition, dentists who offer highly effective in-office treatment should take steps to prevent or reduce side effects by minimizing agent contact with tissues.11
Timing of treatment may also be an issue, as whitening has been known to have detrimental effects on bonding agents in restorations.12
Informed Consent
Patient expectations are an important factor in their ultimate satisfaction. Therefore, they should be made fully aware of the limitations of treatment and what is required to maintain results. Patients whose staining is a result of tetracycline, which is most resistant to treatment, need to understand that best results may not meet their expectations and that whiter teeth may require a different approach, such as veneers. Patients also need to be aware that the factors that contributed to their staining, such as red wine, coffee, and tobacco, will erode results, and that they need to consider their lifestyle and approaches to maintenance, including home treatments, additional treatments, etc.
Patients whose expectations are unrealistic or who are otherwise unlikely to be satisfied with treatments the dental office is equipped to provide should be discouraged from pursuing treatment.
The Different Whitening Options
The ADA Statement on the Safety and Effectiveness of Tooth Whitening Products defines "whitening" as “any process that will make teeth appear whiter.”7 This can be achieved either by changing the natural tooth color using bleaching products with peroxide to remove both intrinsic and extrinsic stains or using physical or chemical agents to help remove surface stains only (Figure 1 through Figure 3).
The main categories of tooth whitening/bleaching treatments include: those that are professionally applied in the dental office; those that are dentist-prescribed/dispensed for home-use; and consumer-purchased and applied over-the-counter products.
Doctors who offer whitening options should recommend and sell only proven products they believe in by companies they trust. Whether services are delivered in the office or are prescribed for in-home use and supervised, they should be carefully selected with the individual in mind. Even high-quality over-the-counter products can be offered through the office to ensure that patients receive the best results and instructions.
Variations among whitening products include concentration of bleaching material, delivery method, and added agents. The objective is to choose a method/ product that is best suited to the individual patient’s dentition and situation. The use of high-quality and appropriate products helps to improve outcomes and increase patient satisfaction.
Whitening Methods from the Dentist
In-Office Whitening
In-office whitening is performed by the dental team, which has the resources to adjust treatment according to patient’s needs. It is the most expensive method, but offers significant advantages including that because the dentist is in complete control of the process, he or she can focus on specific teeth, treat issues such as sensitivity, or discontinue treatment if there is a more serious problem.4 In addition, its effectiveness does not hinge on patient compliance. According to the American Academy of Cosmetic Dentistry, in-office teeth whitening, which affects only the front eight teeth, is the preferred whitening method.4 “The best whitening systems feature a buffer in the gel that protects the tooth enamel from damage, are extremely effective, and can transform teeth in a single office visit. It is a great jump start for take-home whitening, which is always part of an effective whitening program.”4
There are many professionally applied tooth-bleaching products used by dentists in the office. These products use hydrogen peroxide in concentrations ranging from 25% to 40%. Prior to application of professional products, gum tissues are protected either by isolation with a rubber dam or application of a gel6 (Figure 4).
Dentists should inform patients at the outset that they will likely need between two and six treatments—the cost of which should be specified—to achieve satisfactory results, and that the wait time for shade stabilization is at least 2 weeks and can be as much as 6 weeks for higher concentrations of material.13
At-Home Prescribed Products
The FDA regulates the safety, sale, and marketing of at-home tooth-whitening agents, including those that are prescribed, dentist-provided OTC-strength products, and traditional over-the-counter products. These products are eligible for the ADA Seal of Acceptance.7
With the at-home dentist-prescribed products, the patient applies the prescribed agent at home using a custom-fitted tray (Figure 5 and Figure 6). Most commonly, this involves the use of 10% to 16% concentration of carbamide peroxide (CP), which is active for up to 10 hours, and may be used overnight. Also available are day-wear pre-filled disposable trays worn for 30 to 60 minutes, the period of time during which the CP in them is active (Figure 7). The dentist may also recommend a stronger agent for a shorter period of time.14
This option is less expensive than in-office treatment and enables the patient to enjoy the convenience of using prescription-strength products at home, although noticeable results usually require a week or more of daily treatment.
Even patients who receive in-office treatment usually continue tooth whitening at home to maintain results.15
At-Home OTC Whitening Provided by the Dental Office
Dentists can also offer their patients proven OTC whitening products as an entry-level alternative for patients considering purchasing store products with unknown efficacy. This enables patients to receive benefits such as instruction from the dental team and the convenience of pre-made, pre-filled trays.
Other Products to Recommend and Dispense in the Dental Office
Dentists who take the lead as their patients’ whitening resource can provide other products that support their patients’ desire to have whiter teeth. Therefore, in addition to the initially prescribed or recommended OTC whitening products, these practitioners can provide product refills and appropriate ancillary products that support whitening goals, including whitening toothpaste, whitening probiotic mints, and whitening mouthrinses.
Practitioners can also provide appropriate hygiene and treatment-related products such as therapeutic mouthrinses, irrigators and solutions, anti-cavity products, and anti-sensitivity products.
Conclusion
As long as patients want whiter teeth, their dentists can and should help them to reach their goals safely and effectively with proven methods tailored to their individual situation. This win-win situation enables dentists to benefit financially while ethically providing the oral-health–related products and services their patients desire. It is also in alignment with the ADA-stated position on Marketing or Sale of Products or Procedures. “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.”16
Clearly, patients are not only receptive to the dental team’s efforts to identify and support their whitening goals, they welcome the opportunity to receive the most effective esthetic treatments from the professionals they trust to protect their oral health.
References
1. Levin RP. Eight Permanent Game-Changers For Today’s Dentist. https://www.dentaleconomics.com/articles/print/volume-102/issue-10/practice/eight-permanent-game-changers-for-todays-dentist.html. Accessed May 21, 2014.
2. Biery ME. U.S. recession effects gnaw at dentists' business. https://www.forbes.com/sites/sageworks/2011/10/05/u-s-recession-effects-gnaw-at-dentists-business. Accessed May 21, 2014.
3. Horrocks H, Mark Dilatush M. Practice Marketing Essentials. Inside Dentistry. 2013;9(2). https://www.dentalaegis.com/id/2013/02/practice-marketing-essentials. Accessed May 20, 2014.
4. Teeth Whitening. American Academy of Cosmetic Dentistry. https://www.aacd.com/whitening. Accessed May 20, 2014.
5. Ganatra R. Five Surefile ways to boost revenue with chairside teeth whitening. Dental Economics. 2011;101(12). https://www.dentaleconomics.com/articles/print/volume-101/issue-12/features/five-surefire-ways-to-boost-revenue-with-chairside-teeth-whitening.html. Accessed May 29, 2014.
6. Tooth whitening/bleaching: treatment considerations for dentists and their patients. ADA Council on Scientific Affairs. September 2009 (revised November 2010). https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/ada_house_of_delegates_whitening_report.ashx. Accessed May 28, 2014.
7. American Dental Association. Statement on the Safety and Effectiveness of Tooth Whitening Products. Adopted by the Council on Scientific Affairs (April 2012). https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-the-safety-and-effectiveness-of-tooth. Accessed May 20, 2014.
8. Haywood VB. The pre-bleaching exam: components and considerations. Inside Dental Assisting. January/February 2013. www.cdeworld.com/courses/4650. Accessed April 15, 2013.
9. Haywood VB, DiAngelis AJ. Bleaching the single dark tooth. Inside Dentistry. 2010;6(8):42-52.
10. Baer C. The basics of tooth whitening options. Inside Dental Assisting. Nov/Dec 2013; 9(6). https://www.dentalaegis.com/ida/2013/12/the-basics-of-tooth-whitening-options. Accessed May 29, 2014.
11. Baer C. Tooth Whitening Options to Enhance Patient Care. CDE World. September 2013. https://cdeworld.com/courses/4699. Accessed May 29, 2014.
12. Attin T, Hannig C, Wiegand A, Attin R. Effect of bleaching on restorative materials and restorations—a systematic review. Dent Mater 2004. 20:852-61.
13. Haywood VB. In-office bleaching: Lights, applications, and outcomes. Current Practice. 2009;6(4).
14. da Costa J. The tooth-whitening process: an update. Compend Contin Educ Dent. 2012; Nov/Dec. https://cdeworld.com/courses/4633-The_Tooth-Whitening_Process:An_Update. Accessed May 30, 2014.
15. da Costa JB, McPharlin R, Paravina RD, Ferracane JL. Comparison of at-home and in-office tooth whitening using a novel shade guide. Oper Dent. 2010;35(4):381-388.
16. Report and Advisory Opinion of the Council on Ethics, Bylaws and Judicial Affairs: Marketing or Sale of Products or Procedures https://www.ada.org/~/media/ADA/About%20the%20ADA/Files/Final_Report_on_Adv_Op_5_D_2_7-28-99-S.ashx. Accessed May 30, 2014.
