INTRODUCING WHITENING WITH THE RIGHT COMMUNICATION PROTOCOL IN CLINIC
Authors: Dr. Rumpa Wig
Myth 1: 8 – 10 shades possible ?what does it mean ?
Factual Truth 1 : Re-arrange shade guide as per chroma ( light to dark ) and not on hue ( colour ) . Result of 10 shade jump is achieved fastest with an in-office power bleach system.
Myth 2 : Higher the concentration peroxide … better the result ?
Factual Truth 2 :Just because you use the highest peroxide does not mean you will get the best possible whitening result. Infact you are adviced by the ADA to use peroxide of as low a concentration as possible. The role of catalysts and sensitivity markers have been proven to aid whitening and optimal results can be obtained with lower concentrations of peroxide.
Myth 3 : Do Tooth Whitening lights really work to better whitening results ?
FatualTruth :Its not the light but the chemistry between the light and gel that needs to be checked. Most lights have a heat chemistry with the gel to hasten oxidation. This just hastens the effect , does not better it. Lights like ‘Zoom’ have a photo-reactive chemistry with the gel that betters whitening by 3X with minimal heat . Therefore it uses only 25% hydrogen peroxide. B1 in 45 mins in most patients.
Myth 4 : Is Fluoride the final authority on sensitivity ?
Factual Truth 4 : No, Fluoride is not the final authority on sensitivity management . It is best achieved in combination of ACP ( amorphous Calcium Phosphate ) + Fluoride + Kno3 . ACP is an very important new entrant in management of sensitivity as it enhances the uptake of fluoride and synergistically aids enamel care to result in much better sensitivity management than achieved by fluoride alone. Proven and supported by the ADA .
Myth no 5 : Whitening is ‘want based ‘ dentistry ! Should treatment focus be Vanity or Dentistry ?
Factual Truth no 5 :Bleaching is a ‘want based’ treatment option . ‘ACP whitening’ is not. With ACP whitening , it is easier to promote oral health , wellbeing and healing to preserve and conserve what nature gave us before you promote Cosmetic Dentistry. ACP whitening is the only process where you can repair enamel erosion and provide strength and preventive care while whitening. It Remineralises the tooth enamel with essential calcium and fluoride to achieve better care while whitening. We now have the opportunity to metamorph and align with our patient’s NEED for PROACTIVE CARE &Oral WELLNESS ’ with a whiter brighter smile !
Myth no 6 : Difficult to sell whitening in Practice .
There are 3 main rules to keep in mind in Professional Practice ; Inform your patients ( talk benefits ) Don’t sell to them. Recommend to your patients( solutions for their needs / wants ) Don’t sell to them. Showcase the procedure/cases done on your patients( motivate ) Don’t sell to them Whitening is professional procedure just like other procedures in your practice. The only difference is, we tend to think of it as an easy, self explanatory procedure but the truth is , it needs more communication than other procedures in your office. Factual Truth no 6 : Providing interesting and motivating information aids ( white smile artwork , whitening brochures , table displays , e-mailers , whitening TV presentations , Ipad videos, makeover displays with feedback etc ) , promoting health and proactive Oral wellbeing instead of ‘Just’ whitening , building a pre-determined documented & guided communication Flow from reception to assistant to dentist- in clinic, may be a palatable approach to reach out to the patient with reference to whitening .
Myth no 7 : Whitening is Erratic & Unpredictable!
Introduction :
Taking the time and giving enough attention to Patient screening and selection is the first and most important step in a whitening case. A’trial and error’ approach is not something one should consider for whitening. Predictability is achieved with whitening only after the case is understood and treated in a customized manner. It is important to understand, how realistic we can get with results for each candidate .
When we use standard procedure and materials, the result is quite predictable and satisfactory as researched by the companies .
What needs to be assessed in our practice is the unpredictable ( unique … every case id is so different )part or variable factor which is :
In short, the case itself !
Handling the ‘unpredictable’ requires effective screening to obtain a treatment plan which reduces unpleasant surprises that the treatment may offer and effectively reaches the goal result that can be realistically expected taking good care of the variables of the case itself.
Categorizing the cases into :-
is important to decide on a treatment plan and a realistic result. . Whitening should not be a one- time appointment , it needs to maintained …. Just like say …. Hair colour or face bleaching .
One-appointment-whitening . Happens with an In-Office Whitening session . Here too, a combination therapy optimizes the result. The treatment starts in the dental clinic , but needs to be maintained at home . Maintenance requirements also need to be assessed during screening and communicated to the patient.
Let us set few protocols for patient selection,with a few pointers mentioned below,and see how much more predictable the results can get !
Put emphasis on patient evaluation and selection in your practice and set protocols for screening before whitening :
Not every patient who wants whitening, is necessarilyan appropriate candidate, based on a number of considerations. Patient responses to whitening will vary due to habits, tooth structure and current oral health status. It is necessary to note which teeth will respond to whitening more easily and which may not so that we can guide the patient to effective treatment regimen and products that would provide them optimal results in their case.
It is our responsibility,as dental professionals, to determine if a patient is a viable candidate for whitening through
Categorize patients so as to set realistic expectations.
PRO- WHITENING -
Yellow staining from aging, tobacco, dark cola, tea, coffee and red wine will achieve thegreat success with this procedure. Those patients with grey shading from tetracycline or other chemicals may experience less dramatic results, but should expect improvement from this brief procedure.
In most cases , especially those patients with severe stains , even deep stains , the use of aChairsideLight assisted System ( like Zoom ) in combination with take home products( NiteWhite, DaywhiteACP )will provide the greatest results in the shortestperiod of time. It is recommended that all patientsreceive an oral prophylaxis / Prophy Hygiene appointment prior to their tooth whitening appointment. Also, stronglyrecommended , is to end the whitening case with remineralisation and prophy polishing for optimal stable results.
PRO- WHITENING -
Yellow staining from aging, tobacco, dark cola, tea, coffee and red wine will achieve thegreat success with this procedure. Those patients with grey shading from tetracycline or other chemicals may experience less dramatic results, but should expect improvement from this brief procedure.
In most cases , especially those patients with severe stains , even deep stains , the use of aChairsideLight assisted System ( like Zoom ) in combination with take home products( NiteWhite, DaywhiteACP )will provide the greatest results in the shortestperiod of time. It is recommended that all patientsreceive an oral prophylaxis / Prophy Hygiene appointment prior to their tooth whitening appointment. Also, stronglyrecommended , is to end the whitening case with remineralisation and prophy polishing for optimal stable results.
Patient profiles most suited for whitening:
Good age group to indulge in whitening is 20 – 55.
History Checklist before we make a Treatment Regimen decision :
It is paramount that the patient be absolutely comfortable and relaxed with the options and the treatment and the same be discussed with expectations in detail with the patient.
Having a complete range of material shelps, so that we can offer a customized option for each case. We can also choose the concentration that’s most appropriate for their needs, whitening goals and sensitivity levels.
Whitening is contraindicated for:
Patients with anterior restorative work especially veneers ,and patients with multiple restorations must be aware that whitening does not alter the colour of the restorations. . All will need to be re-done if whitening is considered.
Conditions less responsive towhitening include:
We may need to take a critical decision regarding a patient , who :-
Managingthe patient’s expectations is vital
We advise that you do not make predictions or promises to your patients regarding what level of whitening they are likely to experience. You can show them other patients’ “before and after” photos to give them an idea of how successful the treatments can be, but every patient is different and results will vary. That’s why you should offerwhitening options so that you can treat eachpatient individually according to their needs, lifestyle,and preferences.
My Product of Choice– Zoom : In-office ( single to 2 runs of 15 mins ) followed by Tray assisted Nitewhite ACP .
Conclusion :
Whitening is not erratic and unpredictable if we select& assess our patient carefully and then build a treatment plan . Optimum whitening can be achieved that ispredictable if the lessons learnt from screening are addressed in the treatment plan & a final goal or result that could be expected is discussed and accepted by patient and the dentist.
It may take a combination therapy of supervised and at home maintenance to get best results. An important tip for case evaluation is to take the time to understand and accommodate the Patient’s needs, lifestyle& preferences but suggest treatment mainly on the Oral evaluation, Tooth condition, shade Assessment and type of stains on the tooth .
For best results the patient must not be in the contra-indicated or less responsive zone . There is a small percentage , less than 5%, that just do not respond to whitening due to density of tooth structure.
Options : Philips Oral Healthcare range of Whitening
Myth 1: 8 – 10 shades possible ?what does it mean ?
Factual Truth 1 : Re-arrange shade guide as per chroma ( light to dark ) and not on hue ( colour ) . Result of 10 shade jump is achieved fastest with an in-office power bleach system.
Myth 2 : Higher the concentration peroxide … better the result ?
Factual Truth 2 :Just because you use the highest peroxide does not mean you will get the best possible whitening result. Infact you are adviced by the ADA to use peroxide of as low a concentration as possible. The role of catalysts and sensitivity markers have been proven to aid whitening and optimal results can be obtained with lower concentrations of peroxide.
Myth 3 : Do Tooth Whitening lights really work to better whitening results ?
FatualTruth :Its not the light but the chemistry between the light and gel that needs to be checked. Most lights have a heat chemistry with the gel to hasten oxidation. This just hastens the effect , does not better it. Lights like ‘Zoom’ have a photo-reactive chemistry with the gel that betters whitening by 3X with minimal heat . Therefore it uses only 25% hydrogen peroxide. B1 in 45 mins in most patients.
Myth 4 : Is Fluoride the final authority on sensitivity ?
Factual Truth 4 : No, Fluoride is not the final authority on sensitivity management . It is best achieved in combination of ACP ( amorphous Calcium Phosphate ) + Fluoride + Kno3 . ACP is an very important new entrant in management of sensitivity as it enhances the uptake of fluoride and synergistically aids enamel care to result in much better sensitivity management than achieved by fluoride alone. Proven and supported by the ADA .
Myth no 5 : Whitening is ‘want based ‘ dentistry ! Should treatment focus be Vanity or Dentistry ?
Factual Truth no 5 :Bleaching is a ‘want based’ treatment option . ‘ACP whitening’ is not. With ACP whitening , it is easier to promote oral health , wellbeing and healing to preserve and conserve what nature gave us before you promote Cosmetic Dentistry. ACP whitening is the only process where you can repair enamel erosion and provide strength and preventive care while whitening. It Remineralises the tooth enamel with essential calcium and fluoride to achieve better care while whitening. We now have the opportunity to metamorph and align with our patient’s NEED for PROACTIVE CARE &Oral WELLNESS ’ with a whiter brighter smile !
Myth no 6 : Difficult to sell whitening in Practice .
There are 3 main rules to keep in mind in Professional Practice ; Inform your patients ( talk benefits ) Don’t sell to them. Recommend to your patients( solutions for their needs / wants ) Don’t sell to them. Showcase the procedure/cases done on your patients( motivate ) Don’t sell to them Whitening is professional procedure just like other procedures in your practice. The only difference is, we tend to think of it as an easy, self explanatory procedure but the truth is , it needs more communication than other procedures in your office. Factual Truth no 6 : Providing interesting and motivating information aids ( white smile artwork , whitening brochures , table displays , e-mailers , whitening TV presentations , Ipad videos, makeover displays with feedback etc ) , promoting health and proactive Oral wellbeing instead of ‘Just’ whitening , building a pre-determined documented & guided communication Flow from reception to assistant to dentist- in clinic, may be a palatable approach to reach out to the patient with reference to whitening .
Myth no 7 : Whitening is Erratic & Unpredictable!
Introduction :
Taking the time and giving enough attention to Patient screening and selection is the first and most important step in a whitening case. A’trial and error’ approach is not something one should consider for whitening. Predictability is achieved with whitening only after the case is understood and treated in a customized manner. It is important to understand, how realistic we can get with results for each candidate .
When we use standard procedure and materials, the result is quite predictable and satisfactory as researched by the companies .
What needs to be assessed in our practice is the unpredictable ( unique … every case id is so different )part or variable factor which is :
- The tooth
- Its density
- The amount & depth of staining,
- Sensitivity threshold
- Patients’ lifestyle ,
- Oral health,hygiene& diet etc
In short, the case itself !
Handling the ‘unpredictable’ requires effective screening to obtain a treatment plan which reduces unpleasant surprises that the treatment may offer and effectively reaches the goal result that can be realistically expected taking good care of the variables of the case itself.
Categorizing the cases into :-
- Good case for whitening ,
- Less responsive case for whitening and
- Contraindicated patients
is important to decide on a treatment plan and a realistic result. . Whitening should not be a one- time appointment , it needs to maintained …. Just like say …. Hair colour or face bleaching .
One-appointment-whitening . Happens with an In-Office Whitening session . Here too, a combination therapy optimizes the result. The treatment starts in the dental clinic , but needs to be maintained at home . Maintenance requirements also need to be assessed during screening and communicated to the patient.
Let us set few protocols for patient selection,with a few pointers mentioned below,and see how much more predictable the results can get !
Put emphasis on patient evaluation and selection in your practice and set protocols for screening before whitening :
Not every patient who wants whitening, is necessarilyan appropriate candidate, based on a number of considerations. Patient responses to whitening will vary due to habits, tooth structure and current oral health status. It is necessary to note which teeth will respond to whitening more easily and which may not so that we can guide the patient to effective treatment regimen and products that would provide them optimal results in their case.
It is our responsibility,as dental professionals, to determine if a patient is a viable candidate for whitening through
- Lifestyle assessment– habits, diet, personality, profession, time availability and overall motivational levels need to be assessed. Smoking , tobacco , wine etc are stain contributors.
- Oral health, Hygiene and Sensitivity Assessment: An oral exam, X rays to check for enamel cracks and micro-fractures , sensitivity tests (hot & cold test and tapping test ) , including a shade assessment. A prophy Hygiene appointment is great pre-whitening to get to know the teeth and oral status better and prepare for whitening. It ensures better results because whitening is actually an extension of hygiene. . Bad Oral health, must be improved before whitening option is offered. I also use the transillumination test for assessment before whitening.
- A dental transillumination test uses light source (Preferably LED) behind the tooth to reflect & reveal problems in the teeth that can't be seen with the naked eye or with x-rays. Decay appears dense and opaque and often discoloured, while healthy tooth structure is lighter, as light shines through it more easily. A dental transillumination test is especially effective in detecting decay under old fillings. It can also reveal fine cracks in the teeth. These cause severe sensitivity during whitening.
- Sensitivity Assessment-Sensitivity is the biggest problem faced during whitening and special attention be given to sensitivity screening prior to procedure . It should be imperative that the patient is treated for sensitivity before treatment. This is best achieved by synergistic combination of calcium and fluoride. My personal favorite is the Relief gel from Philips (discussed in an earlier article ) which contains the triple formulation of ACP , Fluoride and KNO3.
- Shade Assessment - Its recommended that we assess a patient’s current shade using the VITAPAN Classic Shade Guide™ in value order (brightest to darkest).
It is important to manage patient expectations based on the findings of the oral exam to ensure patient satisfaction.
Categorize patients so as to set realistic expectations.
PRO- WHITENING -
Yellow staining from aging, tobacco, dark cola, tea, coffee and red wine will achieve thegreat success with this procedure. Those patients with grey shading from tetracycline or other chemicals may experience less dramatic results, but should expect improvement from this brief procedure.
In most cases , especially those patients with severe stains , even deep stains , the use of aChairsideLight assisted System ( like Zoom ) in combination with take home products( NiteWhite, DaywhiteACP )will provide the greatest results in the shortestperiod of time. It is recommended that all patientsreceive an oral prophylaxis / Prophy Hygiene appointment prior to their tooth whitening appointment. Also, stronglyrecommended , is to end the whitening case with remineralisation and prophy polishing for optimal stable results.
PRO- WHITENING -
Yellow staining from aging, tobacco, dark cola, tea, coffee and red wine will achieve thegreat success with this procedure. Those patients with grey shading from tetracycline or other chemicals may experience less dramatic results, but should expect improvement from this brief procedure.
In most cases , especially those patients with severe stains , even deep stains , the use of aChairsideLight assisted System ( like Zoom ) in combination with take home products( NiteWhite, DaywhiteACP )will provide the greatest results in the shortestperiod of time. It is recommended that all patientsreceive an oral prophylaxis / Prophy Hygiene appointment prior to their tooth whitening appointment. Also, stronglyrecommended , is to end the whitening case with remineralisation and prophy polishing for optimal stable results.
Patient profiles most suited for whitening:
- People that are conscious about their look and appearance .
- Professionals that require social and networking skills. ( marketing , business development , CEOs , PR )
- Professionals in the entertainment and Hospitality industry.
- People looking to improve change their image and personality ( makeovers ) to younger fresher look .
- Whitening is not cheap and needs maintenance so people that have lifestyles to maintain socially would be good whitening candidates.
- People getting married or having an event to prepare for.
- People who believe in taking care of themselves and keeping the best look they can have. They often visit Spas , salons and gymnasiums .
Good age group to indulge in whitening is 20 – 55.
History Checklist before we make a Treatment Regimen decision :
- Shade assessment with patient medical history
- Oral health assessment. Crowns, bridges , restorative work already done.
- Has the patient whitened before? How long ago?
- Time considerations – is my patient in a hurry for results?
- Would they prefer professional supervision, in-office treatment only?
- Can the patient wear a tray for extended time periods?
- Is the patient a smoker or wine drinker?
- Compulsive tea or coffee drinker?
- Other lifestyle considerations that could affect whitening .eg excessive masala foods esp turmeric.
- Any special occasion for whitening? Perhaps a patient is getting married in the near future, or wants to look their best for a job interview.
- Is the patient looking for immediate results or time constraints are not an issue?
- Economics and motivation to spend .Budgets: short term and long term.
It is paramount that the patient be absolutely comfortable and relaxed with the options and the treatment and the same be discussed with expectations in detail with the patient.
Having a complete range of material shelps, so that we can offer a customized option for each case. We can also choose the concentration that’s most appropriate for their needs, whitening goals and sensitivity levels.
Whitening is contraindicated for:
- Pregnant and nursing mothers.
- Those with AIDS or compromised immune systems.
- Patients undergoing chemo and/or radiation therapy.
- Patients with severely compromised overall oral health/ hygiene.
- Patients with immature dentition (usually under 13years of age), though some patients aged 6-11 have been treated successfully.
Patients with anterior restorative work especially veneers ,and patients with multiple restorations must be aware that whitening does not alter the colour of the restorations. . All will need to be re-done if whitening is considered.
Conditions less responsive towhitening include:
- Shades in the VITA C and D ranges
- Grey stains
- Abfractions
- Worn incisal edges
- Misaligned teeth
- X-rays that reveal receded or calcifiedpulp chambers (Patients with bruxism or malopposed teeth will experience sensitivity and are harder to bleach )
We may need to take a critical decision regarding a patient , who :-
- Isperio-involved,
- Has excessive wear or enamel erosion
- Exhibits micro leakagearound amalgams,
- Has a sensitive gag reflex,
- An unhealthy oral state.
- Bleaching will not lighten porcelain, composite or any other restorative material. Overly restored mouths may not be suitable for whitening.
- High medication
- Lifestyle disease patients like diabetics ,hypertensives , cardiac patients need special care.
- Tetracycline stainsare those that are received through drugs and form an inherent part of the tooth. These teeth respond to whitening with a combination therapy of In-office kickstart and slow at- home therapy with remineralisation with calcium ( ACP ) and Fluoride , which is vital. Setting a realistic target with a cleaner look, instead of B1& beyond , is important.
- Fluorosis Stains: The white spots in fluorosis tend to get more pronounced after whitening , This settles down as the tooth is rehydrated and mineralized post whitening within a few days. The objective for whitening these teeth, is to get the base shade of the tooth whiter so that it better able to blend with the white-spots . While doing so it is important to remineralise the tooth and improve its general health as well. The objective can never be to get rid of all the white-spots as is often suggested or to get the shades to a B1 or less shade with an 8 - shade jump.
- These treatment cases require a low concentration of peroxide and higher degree of treatment to strengthen and remineralise the tooth while whitening.
- People that are above the age of 70.
- People that have bad hygiene and lack of motivation to maintain their looks.
- People on high medication
- Patient with high emotional stress – restless , anxious , Psychotic, OCD’s and distressed individuals may not be considered for whitening .
Managingthe patient’s expectations is vital
We advise that you do not make predictions or promises to your patients regarding what level of whitening they are likely to experience. You can show them other patients’ “before and after” photos to give them an idea of how successful the treatments can be, but every patient is different and results will vary. That’s why you should offerwhitening options so that you can treat eachpatient individually according to their needs, lifestyle,and preferences.
My Product of Choice– Zoom : In-office ( single to 2 runs of 15 mins ) followed by Tray assisted Nitewhite ACP .
Conclusion :
Whitening is not erratic and unpredictable if we select& assess our patient carefully and then build a treatment plan . Optimum whitening can be achieved that ispredictable if the lessons learnt from screening are addressed in the treatment plan & a final goal or result that could be expected is discussed and accepted by patient and the dentist.
It may take a combination therapy of supervised and at home maintenance to get best results. An important tip for case evaluation is to take the time to understand and accommodate the Patient’s needs, lifestyle& preferences but suggest treatment mainly on the Oral evaluation, Tooth condition, shade Assessment and type of stains on the tooth .
For best results the patient must not be in the contra-indicated or less responsive zone . There is a small percentage , less than 5%, that just do not respond to whitening due to density of tooth structure.
Options : Philips Oral Healthcare range of Whitening