It wasn't long ago that we dentist's told people "If you pick a shade too light for your new teeth, they'll look fake". We steered them away from B1 on the shade guide because it was "too light". How old fashioned. There was even a time when we actually tried to make the new teeth the same color as the one's they already had. Today, there is no such thing as "too light", and "natural" is too subjective to even consider.
Bleaching is certainly a reality in everyday practice for most of us. It has become very predictable, profitable, and the public perception is very positive. We charge $150 for the first arch and $100 for the second arch, which is less than most offices. It is still quite profitable because the staff are trained to do most of the grunt work and marketing. The key, as with many procedures done in an efficient office, is to have a well trained, knowledgeable staff that handles the majority of the duties and explanations. We dentist's oversee and handle unusual questions or problems.
The really neat thing about bleaching is that it kind of sells itself, the patients really want it, it's fairly predictable, it helps patients to want other procedures, it's profitable, and it's easy for the staff to do.
Sparking an interest = smile art
There isn't much of a need to "push" bleaching. Most of it is sold before the patient gets to our office. TV ads, magazines, and even talk shows are doing the majority of the marketing for us. We just have to convince the patient that we have an effective, cost efficient way of doing what they want. Usually during a hygiene appointment, the patient will ask the hygienist about our bleaching. Often it starts like "Hey nurse, does them there Crest Strips work?" or "Will my teeth get 20 shades whiter with that whitening paste on that midnight TV infomercial?" It is one of the few dental procedures that patients actually ask for without high tech diagnostics and professional coercion.
Smile art is cool these days for internal marketing. Many practitioners have walls filled with before and after smiles that may influence a patients decision on a restorative procedure. As effective as photos can be, walking billboards are better. The entire staff should bleach their teeth including the Doctor; this is your best bleach marketing. They alone will "sell" most of the bleaching. Not only will their pearly whites glow, they will gain experience needed to answer basic questions the patients come up with. This will make the entire procedure more efficient.
Inside each hygiene room there should be before and after photos of your patients so the patient can see what your bleaching results look like. When the dentist arrives in the hygiene room, just reinforce what the hygienist has already told the patient. Most of the big bleaching companies provide you with nice brochures, posters, and charts which can be subtly displayed in the reception area and treatment rooms, but there is nothing like showing off your own cases. With digital cameras and inkjet printers it is supper easy for dentists to promote their own work.
Materials and methods = fast, slow, or in-between
So many systems, so little time. There are 3 basic categories for dental bleaching now:
1. take home bleaching
2. in office power bleaching
3. office assisted home bleaching
Is bleaching "better" going fast with some cool, high tech light? Is sensitivity less if we go slower? Will teeth get brighter with hydrogen peroxide or carbamide peroxide? If we do a potent booster bleaching at the office before sending the patient home, will the cost in materials and office time be worth it? Do we continue to use higher and higher percentages until the gingival sloughs, and do we charge for a gingivectomy if it does? Are reservoirs recommended just so companies can sell more block out resin and bleaching materials? Does fluoride or potassium nitrate added help with sensitivity?
It seems like every time we order there is a new concentration of material with more goodies added to it. Certainly, since we dentists think bleaching should continue to be managed, supervised, and dispensed inside a dental office, we owe it to our patients to be "up" on the research and recommendations by actual dentists and researchers. We should not get our bleaching information only from sales people, Ladies Home Journal, or on Oprah. At the very least, all dentists should consider subscribing to Reality, CRA Newsletter, or other independent evaluators so that we aren't swayed quite so much by the hype.
We generally offer 2 basic choices for a patient, 16%-22% carbamide peroxide for those patients who want to wear the tray to bed all night, or a 9.5% hydrogen peroxide for those who want to bleach less than an hour once or twice a day. They both work very well and give the patients some flexibility and control according to their personality.
Higher powered 22% and 30% carbamide peroxide bleaches seem to work well so far but they do irritate the gingival more so the trays should end just above the gingival. This takes a little more time and care to trim the tray. The patient should be instructed to wear the tray for no more than 45 minutes to 1 hour. Material changed in the office or bleaching time shortened if the gums hurt, turn white, or the patient doesn't like the experience.
In our office we quickly look at the color and restorative experience of the teeth and generally let the patient know about how much lighter they will get. We stress that we can't guarantee just how much lighter they will get, but that if they don't whiten at least 2 shades on the Vita shade guide we will give them their money back as long as they follow the instructions. If they already have very white teeth, we explain that whiter may indeed happen, but not as much as someone with darker teeth to start with. For patients that have distinct multi-colored teeth, deep tetracycline-like stain, or splotched or mottled teeth, we let them know that bleaching may be uneven and that bonding may be needed later to "even out" the color.
One appointment, high speed bleaching has a place in our offices. Some patients hate to wear trays and with societies "I gotta have it NOW!" mentality, there are indications for its use. You will have to evaluate these systems and implement them according to your convictions and practice philosophy.
Practice Marketing = Give it away
There is a biblical principal that says that the more we give, the more we get. That certainly can apply in dentistry. Schools, ladies clubs, charities, and many other groups are often looking for things to auction off or sell to raise money. Giving away bleaching is a terrific marketing tool, and it lets the community know just how cutting edge your practice is. Donate a "Free arch of Bleaching" certificate.
Bleaching is a great thing for an office to give because people want it, it is easy and quick for the office, and it is a small overhead procedure. Sure you could have the local middle school raffle off a free molar endo to raise money for their field trip, but that may not turn out to be much of a practice builder. When you donate the bleaching, you may just earn a new patient if you and your office impresses them. Welcome them to the office, give them a tour, and just be pleasant with them; no hard dental selling. Just being friendly and professional will give you a good name in the community and help grow the practice. Also be careful not to count charitable donations as a waste of time if you don't see immediate fruits from your toils. Be consistent with the giving and reward will come eventually.
Some offices hold a "drawing" once a month for those patients who maintain regular recalls. The office pulls out a name, the patient is called, and a free arch of bleaching is done as a reward for being a faithful patient. There are other dentists who take the money they make from some bleaching cases and give it away to help local children charities ? i.e. The Crown Council, Discus Dental. Again, there are greater rewards in dentistry than just a bigger bank account.
Multiplying procedures = bleaching leads to other work
That said, bleaching is financially profitable, especially if it leads to other restorative work. In our office we have many patients that just kind of float along with gnarly looking composites, a diastema, or a grungy old anterior crown. We suggest some cosmetic work at recall appointments but they just don't seem interested. Then one day the vanity bug hits them and then they decide to cruise into the rest of life with better looking choppers. Often bleaching is their first cosmetic experience because it is safe, fairly inexpensive, and requires no "real" dental experience.
If a bleaching kit costs us about $30 or so, we still make money even if you subtract labor and office time. However, the real profitability of bleaching in our office is when it leads to other restorative procedures. Suddenly, after some whitening, patients often see other things about their teeth that don't look so good. Frequently a patient will then have those old composites redone, that diastema closed, or those crowns replaced after seeing the potential of a bright new smile in the mirror. Certainly you must be prepared for this by having restorative systems that have bleaching shades, bone up on composite restorations, and become confident in veneers and all porcelain restorations.
Efficient bleaching = using the staff
If the dentist has to explain the procedure, take the impressions, make the tray, and deliver the materials, efficiency will be lost. The staff should be trained well to do all of these things. Take photos and put them on the wall that shows the staff how to pour models, how to make a tray, and how you want the tray trimmed. Then there will be no upset staffers or patients later. Train them or write a script to answer basic questions:
1. How much material should I put in the tray?
2. How long should I leave the tray in?
3. How many days in a row should I bleach?
4. What if my gums or teeth get sensitive?
5. How often will I have to touch up the bleaching?
6. What are the long term effects on my teeth?
7. How often will I have to buy more bleach?
8. If I have trays from another office, can I buy bleach from you?
9. What if my dog eats my trays?
The most time consuming step in take home bleaching making the impression, pouring it up, then trimming the tray. By far the most efficient way to deliver the goods is to do all of this the day the patient agrees they want to do it. In other words, as soon as the patient says "I'm ready to get white", we are slapping the alginate in the mouth. If the request is made at the hygiene appointment, the hygienist takes the impression.
We have alginate pre-measured in flexible plastic cups stored in a central location next to the impression trays. This save time and mess as alginate doesn't need to be scooped, measure, and slopped on the counter and floor. We just add water to the cup, mix, and load the tray. The cup is just thrown away and the only thing to clean up is the spatula. This saves mixing up those old alginate chunks into future impressions.
The assistant or the hygienist pours it up according to who has time. We use Speed Stone which sets rock hard in about 5 minutes. During this time the assistant or hygienist, whomever has time, explains the procedure to the patient and answers any other questions. An assistant then heats, sucks, and trims the tray according to photos we have mounted on the lab wall. Take photos of retainers, splints, set-ups, procedures, and trays to get consistent results from the staff. The photos are printed and put up on the cabinet or walls so the staff have a quick way to see if things are being done the way the doctor likes. You would skip this step if the doctor likes being frustrated or finds great relief in yelling at the staff.
The staff should be able to deliver the tray, instructions, and bleaching material about 15 minutes after the order was taken. As always, the best time to do a service is the moment the patient is interested. This gives them much less time for the brain to try to rationalize the emotion out of the treatment. Also, the fewer appointments needed for any procedure, the more efficient the office can run. It must be stressed to the patients that like putting fertilizer on the yard, more is not better. Following directions is much more important for success than using more bleach.
Is my office the only one that goofy stuff happens to lab work? Fast delivery is tremendously better for a lot of reasons. It beats sitting an alginate in the lab sink, and remembering to pour it up after the alginate is rock hard the next Monday. Or maybe someone forgets to separate the model from the impression for a week. We attempt a recovery by trying to soak it in water for a few hours only snap the teeth off when separating anyway. If we find the pieces, hopefully the superglue will hold so the tray will fit reasonably well. Or maybe we loose the lab case; if we are really lucky, the patient won't blow chunks again when we retake the impression. Or maybe we just forgot to make the goofy thing until the patient walked in for the next appointment. Those assistants really scramble fast when the receptionist yells "Hey you guys got that bleaching tray ready for Mrs Gates?"
Write a technique guide for the staff to follow on every bleaching patient:
1. Make a treatment plan = patient signs and agrees to fee
2. Hygienist or assistant takes impression = fast set alginate, pre-measured cups
3. Pour up = model made from fast set stone, about 5 minutes (i.e. Speed Stone)
4. Explain procedure while stone setting = explain and show how to use kit
5. Explain bleach options to the patient = all night or an hour once or twice daily
6. Pick a shade = arrange Vita guide chromatically from light to dark
7. Give reasonable expectations = at least 2 shades lighter, perhaps much more
8. Make suck down tray = no reservoir, faster to make and no benefit to patient
9. Deliver tray = explain more is not better, show small amount needed on facial
10. Return for 1 week follow-up = ask about the experience, problems, answer questions
11. Reevaluate and schedule follow-up according to patient experience
Answer questions honestly. The gums can turn white near the tray, the gums can be a bit "achy", and the teeth can be sensitive for a while. But stress that these are temporary and are usually overcome with time off from bleaching or even changing to a weaker concentration. Stress that dental work will not change color during bleaching, this is "Duh" to the dental staff but patients may not understand this concept. Have fun with bleaching. It is a great service to the patients and is a simple, cost effective way to make a drastic change in a patient's smile.
