Tooth Whitening and Total Patient Care

Has a dental procedure ever commanded as much attention from the public as the current tooth-whitening phenomenon? Consumer media articles and advertisements remind patients daily to brighten their smiles, creating a demand for a cosmetic dental procedure that is within reach of the average budget. The low cost of over-the-counter (OTC) products and their retail availability make them accessible to the masses. Even in-office or dentist-prescribed take-home procedures are affordable. They are among the least expensive of all esthetic procedures performed by dental professionals, and are significantly less expensive than any medical/surgical cosmetic procedure. When we combine the low costs, strong advertising, and the sheer presence of individuals seeking youthful appearances with the air-brushed images of Julia Roberts, Britney Spears, or Brad Pitt, dental professionals know that some challenging expectations have been established.

By providing the rationale for professional monitoring of treatment, as well as the latest information about tooth-whitening options, this article will assist the practitioner in harnessing the current enthusiasm for whiter teeth, obtaining the best possible outcomes, and managing the patient's expectations in the context of total dental care.

Living up to expectations

When patients walk through the door of your office, many of their perspectives are based on what the media is telling them. Advertisements sell the idea of tooth whitening in the same manner as nail polish or hair coloring; it is an inexpensive way to improve your looks and your life. In a recent article for Retail Industry, Melody Vargas reports that Leonard Lauder, Chairman of the Estee Lauder Companies, states that over the years, the company has noted that as the U.S. economic prospects decrease, the sales of lipstick increases. This may be because lipstick is a low priced luxury item that helps folks to feel good in difficult times. Today, as patients shift their shopping from high-end department stores to discount chains, they may be shifting their medical cosmetic dollars from the high-end surgical face-lift to more affordable whiter teeth.

The question for the dental professional to ponder is, "What convinces patients to choose your services for professional whitening over the retail store version of a similar product?" Perhaps it is because when patients walk into your office they place the responsibility for the outcome in your hands. In essence, they are saying to you, "I am willing to pay you five to ten times more money for your care, skill, and judgment because I trust you and expect you can achieve the best outcome while assessing any risk to my teeth."

With the responsibility to produce the same kind of results with tooth whitening as we have been able to achieve for our patients with other procedures in our practices, we must understand the treatment options and potential outcomes.

It is important that both the dental team and the patient understand that tooth whitening is a part of a total esthetic, preventive, and restorative treatment plan that is commensurate with the patient's expectations. For example, vital night-guard whitening without consideration of other dental issues may be very successful and achieve absolutely wonderful results under the right circumstances. On the other hand, stains due to amalgam restorations, fluorosis, pulpal trauma, white spots from febrile illnesses, hypocalcification, erosion, or mottled enamel require a more sophisticated treatment than a to achieve biologically sound and esthetic result.

A simple question

A simple question on your office's medical/dental history form — "Are you satisfied with the color of your teeth?" — provides a lead-in for the patient who may be uncomfortable asking your advice on how to look more appealing. This question opens the door for patients to express their esthetic or cosmetic concerns. It provides you with the opportunity to discuss the difference between a self-administered OTC whitening product and an office-supervised professional treatment plan. It also gives you the opportunity to evaluate the type of stain, the existing restorative materials in the mouth, the health of the gingival tissues, and other factors that may affect the treatment outcome. Because dental restorative materials do not respond to peroxide whitening, failure to have this discussion prior to rendering treatment may result in disappointing esthetic results or the need to redo anterior restorations such as veneers, crowns, or composite restorations after the whitening treatment.

Whether it is the dentist, dental hygienist, or dental assistant, the entire staff should fully understand and be able to articulate the following points when discussing whitening options with the patient.

• Safety — Most of 500-plus research-based and published articles that have been written attesting to the safety of the whitening/bleaching procedure are based on the premise of adherence to proper protocol during dentist-supervised treatment. Issues such as over bleaching, reaching the saturation point for enamel, effect on restorative material bond strength, and soft tissue management are but a few of the considerations to discuss in advance with a patient as you recommend their whitening be supervised in your office.

• Managing sensitivity — In a professionally monitored whitening treatment plan, the dental professional is available to help with complications, the most common being sensitivity. Despite claims that some bleaching products do not create tooth sensitivity, double-blind clinical studies have shown that sensitivity occurs in 55 to 75 percent of treatment groups. Treatment with a 2 percent neutral sodium fluoride gel, such as All Solutions™ (Dentsply Professional), applied with a tray before or after the bleaching session, has been reported to successfully reduce sensitivity to the active whitening ingredients.

Orthodontic forces, due to a poorly fitting tray, can also cause sensitivity. This problem can be avoided if the tray is constructed with reservoirs and is made of soft material. The tray should be scalloped and adjusted to not impinge on the gingival or soft tissue, creating sore spots. Patients should be instructed to bring the tray to the office at each evaluation appointment so any adjustments can be professionally performed.

If the sensitivity is not be relieved by any of the above methods, the patient should reduce the amount of time the tray is worn at each treatment session, or adopt an every-other-day treatment schedule.