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Debunking the Bleaching Myths by John Nosti, DMD, FAGD, FACE, FICOI

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by John Nosti, DMD, FAGD, FACE, FICOI

Google doesn't know it all
I know exactly what you are saying. "Seriously, John—an article on bleaching?"

Despite its status as a staple in dentistry for two decades, bleaching still spawns the kind of misconceptions and misinformation that require us to set the record straight. (Dare I say some of this misinformation comes from our fellow dentists?)

In addition, bleaching can be an excellent tool to gain new patients, maintain a full recare schedule, or simply enhance your notoriety as the resident expert in cosmetic dentistry.

In an age when Google and Dr. Oz are our patients' primary source of information, it is steadily becoming more important for us to be well informed regarding the barrage of bad information affecting our patients' decisions on treatment.

For example, simply search "risks of tooth whitening" on Google, and you'll find the top-ranking site is a dental insurance site. Although the first paragraph on this page sounds great, the second paragraph is all about "risks associated with tooth whitening." This site claims the risks include tooth sensitivity and damage to the roots of teeth.

The first myth
This presents a problem to anyone who sees this bad information. I am shocked at how often people tell me, "The reason my teeth are sensitive is because bleach damages the enamel on teeth." True, I have read articles that discuss the effects of bleach on the microhardness of enamel. However, many of these outcomes require a constant bleaching of up to 112 hours.1

Other studies indicate that although there is an effect on enamel hardness during treatment, the effects are quickly reversed following removal of the product, which results in no damage to the tooth structure whatsoever.2

The solution
Providing a new-patient questionnaire addressing bleaching, or simply discussing bleaching during the new-patient exam, will allow you to uncover a patient's misconceptions regarding bleaching. Having bleaching pamphlets or information fact sheets from the American Dental Association on hand will allow you to alleviate your patient's concerns.

In addition, I have found that simply showing patients that my staff and I have used bleaching products dismisses most patients' concerns.

Some websites offer advice as to who are good or bad candidates for bleaching. One example: "Generally, tooth whitening is successful in at least 90 percent of patients. As a rule of thumb, yellow-colored teeth respond well to whitening, while brownish-colored teeth don't respond as well. Gray stains caused by smoking, taking tetracycline, or fluorosis (ingestion of too much fluoride) most likely will not be dramatically changed by tooth whitening."3 This common misconception has not only misled patients, but also dentists. In just the past few months, several new patients told me that their former dentists told them that their teeth could not be bleached.

My solution for patients with dark-gray teeth has been KOR Deep Bleaching. Following the deep-bleaching protocol combination of in-office and take-home applications, it has been my experience that even patients with teeth darker than C4 can enjoy a great result.4

True, it may require several applications that a patient with an A2 preoperative color doesn't require, but the end result has always been something that these patients have been extremely excited about.

Likewise, the cost of treatment for these patients is higher, due to the multiple treatment applications required. Still, the increased cost for bleaching for these patients far outweighs the cost of veneers, the treatment commonly recommended by both dentists and various online resources.

The excitement these patients feel after treatment quickly turns into a source of new-patient referrals, as they cannot help but brag about a result they achieved with bleaching at my office, when elsewhere they were told it could never been done.

The second myth
A patient with existing dental work often believes that he or she is not a candidate for bleaching. Here is another piece of misinformation that I have found online. "Likewise, tooth whitening may not enhance your smile if you've had bonding or tooth-colored fillings placed in your front teeth. The whitener will not affect the color of these materials, and they will not match your newly whitened smile. In these cases, you may want to investigate other options, such as porcelain veneers or dental bonding on other teeth."3

I believe that this paragraph is the most important to address because these opinions, and the choice of wording, are the costliest in terms of lost production in the dental office when it comes to bleaching. If someone has discolored bondings, veneers, or crowns, and they are unhappy with the appearance or shade, why would someone recommend matching these restorations with more restorations?

Or why would veneering the entire smile be an option when someone can simply remove the offending crowns, bondings, or veneers, place temporaries that are lighter, and allow the patient to bleach the teeth that don't require direct or indirect restorations?

Over the years my partner and I have treated countless patients with single or multiple anterior indirect restoration(s) that we replaced following bleaching. The patients couldn't believe that their previous dentists didn't offer to replace the crown or veneers that they were unhappy with. I know what you're saying. "John, you cannot believe everything a patient tells you." Although this may be true, the dentists still communicated to these patients in a manner that made the patient believe that this treatment wasn't possible.

The solution
Make sure you are communicating a clear treatment-plan path to bleach your patient's teeth and replace the existing indirect restorations. This could mean bleaching first and replacing the restorations second, or removing the indirects and placing temporaries for the patient to "bleach up" to. Whichever plan is chosen, make sure the patient has a clear understanding of his or her options.

Bleaching as a new-patient promotion or to increase patient retention
Over the years I have talked with many dentists who have been successful in both attracting new patients and keeping their hygienist's chair full through a popular bleaching program.

The simple program of providing "whitening for life" includes a set of custom trays and one or two syringes of bleach, provided upon completion of the new-patient exam and any necessary treatment required prior to bleaching. At every maintained six-month re-care visit, the patient is provided with another syringe (or two) to maintain or continue bleaching.

The caveat is that the patient must maintain the six-month re-care visit, or reschedule within a set time frame dictated by the office, to remain in the bleaching program.

If the patient misses a hygiene visit, he or she falls out of the program. Of course, you can set a fee requirement for the patient to get back into the program. This program has become so popular that it has become almost routine for many dental offices. In fact, many dentists consider this program a must to remain competitive in their geographic area.

Looking for a way to boost staff morale, and increase your acceptance rate on bleaching? Try offering a bleaching bonus to staff members. Offering a bonus for every bleaching performed in your office can be a quick way to reward staff with some extra cash, especially before the holidays. "White for the holidays" can be a program in which you reward patients with gift certificates that they can then give to friends and family members (or quietly keep for themselves).

This program also can offer shared revenue for staff. In past years, my partner and I have offered a fifty-fifty profit split (after costs of impression material and bleaching materials) to the staff, which turned out to be a success. Make sure that clear start and finish dates are set prior to offering the bonus, to prevent the staff from losing excitement.

You may also consider lowering your overall fee for bleaching during this time to provide incentive for the patients to treat themselves.

The staff feels genuine in their recommendation, knowing that they aren't pushing the products simply because of the bonus, but due to the discount the patient is receiving during this time frame.

In closing
Bleaching still remains one of the most versatile tools for a general and cosmetic office. You may choose to use bleaching as a loss leader to generate new patients, to help maintain a full hygiene schedule, or to allow patients to replace existing unsightly restorations. Or you may use bleaching as a source of untapped revenue through bleaching bonuses with the staff, or differentiate your practice through enhanced deep-bleaching procedures that many offices choose to not offer. Or you may choose "all of the above!"

Whichever way you go, just make sure your office is up-to-date with the most current information and most effective bleaching options available, so that you and your staff can provide your patients with a truly outstanding result!

References
  1. Effect of four different opalescence tooth-whitening products on enamel microhardness. Oral and Dental Research Institute, Faculty of Dentistry, University of the Western Cape, Tygerberg, South Africa. SADJ: journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging 06/2008; 63(5):282-4, 286. Source: PubMed
  2. Effect on Enamel Microhardness of Two Consumer-Available Bleaching Solutions When Compared with a Dentist-Prescribed, Home-Applied Bleaching Solution and a ControlRalph H Leonard · ERICA C.N. TEIXEIRA · Glenn E Garland · André V Ritter. Journal of Esthetic and Restorative Dentistry 02/2005; 17(6):343-50;
  3. Delta Dental https://www.deltadentalins.com/oral_health/bleaching_risks.html
  4. KöR Whitening. Satisfied whitening patients yield more referrals for your practice. John Nosti, DMD, FAGD, FACE, FICOI Inside Dentistry. September 2014, Volume 10, Issue 9.




Dr. John Nosti practices full-time in Mays Landing and Somers Point, New Jersey, as well as Manhattan, New York, with an emphasis on functional cosmetics, full-mouth rehabilitations and TMJ dysfunction. Dr. Nosti's down-to-earth approach and ability to demystify occlusion and all ceramic dentistry has earned him distinction among his peers. He is the clinical director of The Clinical Mastery Series: A continuum geared toward advancing your knowledge in occlusion, aesthetics and restorative dentistry.


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