- Dr. Rodney Ogrin Answers: Whitenings Toughest Questions
- Why Whiten ALL Your Patients?
- How White is Right? – A practical answer to a very central question
- RDH Corner – What Patients Want
- Safety First – Is High Concentration Safe?
- Holiday Marketing
Dr. Rodney Ogrin Answers:
Whitening’s Toughest QuestionsWHY is it best to use the highest at-home concentration available for your patients?
We asked one of the leading whitening experts for an explanation of his strong views about this, as well as a handful of other sizzling whitening issues.
Rodney Ogrin, D.D.S. has been a pioneer of whitening for more than 10 years. He began his career studying full mouth reconstruction under such notables as Niles Guichet, DDS, and Harvey Wipf, DDS. His focus on cosmetic dentistry began in 1985 and included research with two in-house ceramists working with hybrid porcelains for veneers, onlays, and inlays.Dr. Ogrin began dedicating himself to whitening in 1990 when he founded Life-Like Cosmetics, a leading whitening materials manufacturer. A long-time proponent of higher concentrations, Dr. Ogrin’s company was the first to introduce 15%, 20%, and 30% carbamide peroxide strengths for at-home use.Whitener: You’ve become well known for your strong opinions on tooth whitening. Can you explain how your thoughts on tooth whitening differ from others in the whitening community?Dr. Ogrin: bsp;We’ve learned a great deal about whitening over its 10-year history. The good, the bad, and the ugly can be summarized as follows: Yes on high concentration for at-home use, yes on short treatment times, and yes on dual arch bleaching. No on overnight bleaching, no reservoirs, no KNO3, no curing lights, and no on fancy flavor choices. This approach is proving correct, based not only on the science, but on the most important factor of all, what is best for the patient, or what I call, “patient justice.”
Whitener: What is an example of passé whitening vs. a more contemporary approach?
Dr. Ogrin: Why use 10% carbamide peroxide overnight with unnecessary reservoirs and require your patient to bleach for 20 to 28 days when you can do two, 20-30 minute treatments daily on both arches during bathroom routines for 7 to 10 days? Stop and think about it for a minute.
Whitener: So what is the real efficiency advantage of the high-concentration, shor t-treatment- time whitener?
Dr. Ogrin: The science of whitening has pointed us in the right direction. Clinical Research Associates did a study in 1997 showing that approximately 50% of the active ingredient is degraded into water and CO2 in the first 30 minutes. All the major brands were tested. Further, a study by Zaragoza VTM. states that “th e higher the concentration, the greater the effect of the oxidation process.”1
At the end of 30 minutes, twice per day, the 30% fast bleach has entered the the tooth with 300% of the whitening power of the 10% product. Add to that a second application, actually doubling the whitening ower again. In other words, using the 30% at-home, with short treatment times, you will maximize the effectiveness of the patient’s treatment time and achieve th e most bleaching. Who wants to wear a stent for longer than they have to when there’s a better alternative? Why not minimize the time it takes — and maximize the effectiveness? Again, it’s a question of what’s best for the patient.
Whitener: What about the sensitivity using high-concentration, at-home?
Dr. Ogrin: The inventor of the 30%, Robert Drosman, DDS, conducted a 1,400-patient clinical evaluation and statistically verified less than a 5% acute pulpal sensitivity rate. That is only one out of 20 patients. D r. Bill Strupp, a world-class clinician, now whitens ALL of his patients’ teeth with the new fast bleach and reports n o significant difference in sensitivity beyond that of lower concentrations. Since the introduction of 30%, literally thousands of patients have used it to whiten their teeth without pulpal sensi- tivity. Soft tissue irritation is virtually a moot point when the tray is scalloped properly and when the patient follows a few simple dosage instructions.
Whitener: There has been so much dialogue about reservoirs vs. NO reservoirs. Why do you support NO reservoirs?
Dr. Ogrin: Reservoirs seemed like a good idea years ago when the idea first circulated. However, top indepe ndent authorities such as Clinical Research Associates, Van Haywood, DMD, and Reality (Michael Miller, DDS) have refuted the effectiveness of reservoirs. Most of the manufacturers are recommending discontinuing their use. The fact is, reservoirs have gone the way of the dinosaur . . .extinct! They are not in the best interests of the patient, as they put more gel in the trays, making it more available to be swallowed — an especially scary thought when the gel contains KNO3. I teach no reservoirs, a .25 cc dosage, and short 20 to 30 minute treatments — resulting in maximum oxidation per unit of gel. Van der Waal’s forces keep the tray in place, and the thin layer of gel is utilized maximally. The patient then expectorates and rinses with the very least possible amount of bleaching chemicals swallowed.
Whitener: Speaking of KNO3, why are you NOT in support of its use in bleaching gels? Doesn’t it help with sensitivity?
Dr. Ogrin: I believe, as do Michael Miller, DDS, of Reality magazine, Van Haywood, DMD, and Rella Christensen, PhD, of Clinical Research Associates, that zero sensitivity is a misnomer. Again, I refer to authorities such as CRA and the FDA. Until we see a study or statement from an authority discounting the CRA assertion that “when nitrates make contact with amino acids, they convert to nitrosamines, and nitrosamines are one of the most carcinogenic compounds known,” I will not support the addition of KNO3 in bleaching gels. Even animal studies show that resulting nitrites combine with hemoglobin to form methemog lobin, thus decreasing the ability of the blood to carry oxygen. The FDA Federal Register makes it clear that digestive nitrosation is an issue. Further, KNO3 toothpaste includes a warning that if you swallow more than a toothbrush full, you should go immediately to a poison control center. These warnings should suffice as you decide whether you should expose your patient to the chronic swallowing of KNO3. Why place the 19 patients out of 20 who have NO acute pulpal sensitivity at potential risk when that ONE patient can be treated preventively with a KNO3 toothpaste that is expectorated . . . and not swallowed?
Whitener: You mentioned no flavor choices. How can that be important?
Dr. Ogrin: Again, it’s a question of what’s best for the patient. Sure, tasty flavors sound fun, but this is a dental procedure! Flavor is a warning — and not a candy! When the patient tastes these gels, the taste is a warning the tray is overfilled. Pleasant tasting gel does not justify all-night/multiple-hour swallowing of gel.
Whitener: Dual arch, Single arch: What’s the difference?
Dr. Ogrin: It makes a big difference to patients who want whiter teeth now and wish to be done with their treatments. Dual arch whitening is now possible because of fast bleach. Try wearing two stents for an hour or more; it is simply uncomfortable. Additionally, multiple-hour wear time can also cause potential TMJ problems. The other factor is that fast bleach overcomes the need for opposite-arch comparisons. With a fast-acting bleach, patients and their loved ones can easily see the expedient and dramatic difference. They don’t need the contrasting arches for motivation.
Whitener: Given your advocacy for patient issues, what are your thoughts on patient compliance?
Dr. Ogrin: The single most important facet of tooth whitening is patient compliance. Studies tell us that patient compliance after the “new procedure instruction” wanes dramatically after 7-10 days. Since most tooth whitening procedures take 10-14 days per arch, you can see that whitening two arches separately (in 20-28 days) promotes a dramatic decrease in compliance, with the consequence of questionable whitening results. Fast bleach (7-10 days) falls within excellent patient compliance range. Given the informed choice, patients will choose the option to whiten in a matter of minutes verses multiple hours or all night. Furthermore, fast bleaching is a paradigm shift for your new patients. Now your patients can whiten their teeth while in the bathroom. A patient can load her/his tray with gel, bathe, dry, shave, apply cosmetics,then take the trays out, spit, and rinse.
And, voilá! I call that “timeless patient compliance” because it doesn’t demand a dedicated time for bleaching, but fits quickly and seamlessly into most patients’ busy lives.
Whitener: What about the issue of A.D.A. acceptance? You support the use of 30% at home, while the A.D.A. has approved only 10%.
Dr. Ogrin: The A.D.A. will not accept anything except 10% c.p. gels for testing. But the gels sold in the market include 11%, 13%, 15%, 16%, 20%, 22%, and now 30%. All bleaches work! The A.D.A. refuses to test higher concentrations. Available sales data tell us very few dentists use 10% gels for their patients. So, the vast majority of whitening patients are whitened with higher concentrations. Obviously, dentists inherently know that higher concentrations bleach faster and are more predictable. I am not aware of a single lawsuit after years of whitening teeth with higher concentration bleaching gels. Dental science reflects no downsides to enamel, dentin, or the pulp.
Whitener: What is your position on curing lamps?
Dr. Ogrin: They appear to me to be ineffectual and potentially dangerous. Try putting your finger next to the light for three to five seconds and then try to tell yourself there is no risk of pulpal damage. There are studies, such as a recent CRA report, questioning the efficacy beyond the effect of the bleaching gel alone 2. There have been studies available for years re- garding pulpal damage from heat and 35% H2O2. Why put your patients at risk when you can get faster, safer, and better results with 30% at-home?
1. Zaragoza VTM. Bleaching of vital teeth: Technique. Estomodeo 1984; 9:7-30.
2. Clinical Research Associates Newsletter Supplement, Why Resin Curing Lights Do Not Increase Tooth Lightening, Aug. 2000; 1:3″
Why Whiten ALL Your Patients?
In the last issue of the Whitener, an interview with the popular clinician William Strupp, DMD, revealed that he whitens ALL his patients using Life-Like’s 30% at-home gel. What benefit is there to your patients and your practice to whiten all your patients? Is it practical . . . and how do you actually sell the service to 100% of your patients?
There are many key benefits that each and every patient will receive:
* Whiter Smile – Compliments from friends and family go a long way in boosting the perceived value of patients’ dental investments.
* Shade Base for Porcelains – Porcelain does not bleach. So, before caps or veneers are applied, it is important to whiten the teeth first and then match the porcelain. This way, the patient has a shade he/she can always return to by whitening. Matching to a darker shade is not in the best long-term interests of the patient.
* Gingival Health – Remember, whitening was first discovered as a secondary benefit. Its original use was cleaning and debriding the periodontium.
* Whitening Acclimation – Getting patients accustomed to whitening is of great service to them. Touch up whitening and cleaning and debriding should be a lifetime commitment contributing to overall dental health.
But, how is it possible to whiten all your patients? Dr. Strupp tells us his secret. If a patient does not want to whiten due to the cost, he asks them what they will pay. Whatever the answer, he accepts that as the price. By doing so, he knows a whitening patient will be a better patient who cares more about his/her teeth, likes his/her smile better, and has more of an investment in them. He also knows it will help move that patient into other cosmetic procedures – the better the smile, the more the patient appreciates it and is willing to invest further in it. The approach has been a success for Dr. Strupp and will lead your practice to greater patient satisfaction, too.
There are less drastic ways to help patients handle the expense versus the perceived value. Many practices routinely price whitening into a package of dental services. When assembled in a package, it becomes easier to present a complete dental solution.
Another pricing approach is to use whitening as a loss leader to bring in new patients. This approach has proven extremely successful when promoted in print ads, radio spots, flyers, coupons, as well as by word of mouth. Regardless of how you do it, making it routine to whiten ALL your patients is good for your patients — and your practice.
How White is Right?
A practical answer to a very central question.
How does a patient know when their teeth are white enough? This is a valid question that covers the full spectrum of patient expectations. Some patients will ask the question after the first couple of treatments. Some patients will ask the question after going far past the usual whitening regimen in search of a mystical white.
The answer to the question, regardless of where a patient falls in this spectrum, is that there is no known safety limit. Therefore, patients can whiten as long as they’d like. Professional carbamide peroxide whitening has proven itself safe through its 10-year history. Patients can continue to whiten their teeth until they fail to see any significant change. Many patients have been known to regularly apply touch-up treatments. This only pro- motes better oral health and has no known downside.
What shade is the goal? Teeth only get so white depending mostly on the structure and internal color of the teeth. Following the uniqueness of each human body, there is no single prede- termined white that can be achieved by all people. However, Van Haywood, DMD, and other whitening experts teach that the esthetic ideal is to match the sclera (whites) of the eyes.
Regular whitening can also contribute to positive perceptions about one’s smile. Some women, for example, will routinely wear their bleaching trays while applying cosmetics to look their best. They look in the mirror and notice a difference each time. What is truly happening is that they are removing the plaque off the surface of their teeth causing them to shine more. Also, positive expectations always contribute to positive perceptions.
It can be helpful to manage the perceptions of the patient. It is always a good idea to use a shade guide and document in the chart of each patient the before and after shades. Taking a before and after picture is not only helpful to the patient, but can be used for a before-and-after whitening album for your waiting room to help market your whitening services.
It is a good approach to go ahead and give patients plenty of whitening material so they may decide for themselves how much is enough. Avoid the new mini-kits some whitening manufacturers offer and instead always maintain an adequate supply of bleach on hand to support your patients’ whitening needs and perceptions. Even if it requires a recall for additional material, it doesn’t pay to use the mini-kits. A mini-kit is just a pricing gimmick used by some manufacturers to make it seem like they are inexpensive. Compare prices by the cc and then dispense whatever works for your practice.
Another approach to touch-ups for patients who may chronically whiten is to use lower concentrations for cleaning and debriding. Regular use of 10% carbamide peroxide will promote periodontal health as well as help maintain the desired whitening level.
Every patient is going to have to answer this question for themselves, how white is right. The best way to help patients is to encourage them to ask questions so you can help them understand what to expect and how to achieve the right white for them.
What Patients Want
by Victoria DaCosta, RDH
Patient satisfaction is the key to the most powerful marketing tool available, word of mouth. It is those of us who are most “plugged in” to the needs of patients that can help our practices keep these issues at the forefront of our thoughts as we tailor our services. Here are some of the top patient whitening issues measured against the procedures currently available:
* Fast, Predictable Results – Patients want to see results, fast. The faster they reach their desired whiteness, the better. In-office whitening gives patients fast results, but the whitening is incomplete and does not provide a means to treat fadeback. Low concentrations of at-home bleach can take almost a month to achieve the desired results for both arches. Using 30% at-home is the best bet, as it produces the fastest and most predictable results available, 7 to 10 days versus 20 to 28 days for both arches.
* Simplicity – Patients want whitening to be simple. The number of days, the length of treatments, the ease of use of the delivery system all effect how simple whitening is for the patient. Low concentration at-home whiteners score low on this account as they require an inordinate number of days and treat- ments. In-office whitening requires the patient to be treated multiple times to achieve ideal whitening. At-home whitening with 30% is simple because the number of days and treatments are at an absolute minimum. Best yet, the treatments can be accomplished within the patients’ regular bathroom routines so they can fit into their busy lives and not require any special bleaching time. Further, Life-Like’s seal-syringe eliminates messy tips and is the most patient-friendly delivery system available.
* Safety with No Sensitivity – Patients want whitening to be safe and to cause as little discomfort as possible. Despite claims by some whitening gel manufacturers, some patients will have sensitivity regardless of the material used. In-office curing lamps combined with 35% H2O2 have been found to potentially cause pulpal damage. Low concentration at-home whitening is safe but overnight bleaching promotes unnecessary swallowing of gel. At-home 30% fast bleach is safe but must be kept off the soft tissue with proper scalloping and patient dosage instruction.
* Value – Everyone wants the most bang for their buck. In-office procedures fall short here as chair time is expensive and there is only so much bleaching that can be achieved in one session. Low concentration at-home whitening would be a better value if it weren’t for problems with patient compliance. If patients don’t see fast results, compliance so often wanes. Again, 30% at-home shines as patient compliance is greatly enhanced by fast and predictable results. Additionally, when you consider the cost of whitening potency — per cc — the 30% product gives you the very best value to pass on to your patients. Regardless of what you charge — patients who stick with it and who see good results will be walking billboards for the value they received from your office.
Victoria DaCosta, RDH, is a practicing Dental Hygienist, innovator, and President of GumAerobics — a fun & simple treatment for gum disease. Visit her website at www.gumaerobics.com, or E-Mail: email@example.com For more information, call 877/373-4000.
Is High Concentration Safe?
The popularity of 30% carbamide peroxide for at-home use has skyrocketed within the last year. Still, some dentists prefer to stick with 10% to play it safe. This raises the question, is 30% suitable for at-home use? Does such a high concentration potentially compromise the safety of your patients? Here are some key points to consider:
* Whitening Gold Standard – Carbamide Peroxide has been used successfully in dentistry for over 10 years with no history of any kind of problem to enamel, dentin, or pulp.
* Safety Testing – The highest at-home concentration on the market, 30% carbamide peroxide, was tested by an independent laboratory using the ADA protocol for safety. The purpose of the tests was to determine irritation to mucous membranes, i.e. carcino- genicity. The study concluded 30% was not a mucous membrane irritant.
* Patient Study – Before being put on the market, the at-home 30% underwent a 1,400 patient study by the inventor, Robert Drosman, DDS. The study not only found the product to be safe and effective but to have minimal acute pulpal sensitivity of less than 5%.
* Commercial Track Record – Carbamide concentrations of 20% and 22% have been on the market for years. The 30% has now been on the market for over a year. These products have been proving themselves safe in the real world with patients and practices everywhere.
* Faster Hydration – Higher concentrations have safety advantages. The short wear time allows the teeth to rehydrate more quickly. Dehydration is a leading cause of sensitivity. Lower concentrations using overnight modality prevent hydration unnecessarily for hours. Additionally, the 30% product is 20% water which also contributes to hydration.
* Minimal Tissue Irritation – Higher concentrations can irritate soft tissue. However, the effects are minimal and can easily be avoided. Proper scalloping of trays and instruction to the patient to avoid overfilling the trays keeps the gel off the soft tissue. If a patient overfills the tray, soft tissue blanching heals quickly and is reversed within hours.
* Minimized Swallowing – Higher concentration whitening uses no reservoirs and the least amount of wear time. Therefore, the potential to swallow gel is reduced significantly. This is a safety advantage over low concentration gels worn overnight with reservoirs full of gel, most of which will be swallowed.
* Eliminates TMJ Threat – The short wear time of high concentrations, dual arch whitening eliminates the potential for TMJ problems.
Company is coming! Parties are everywhere! ‘Tis the season when almost EVERYone will want to look his or her best.
The holidays are a great time to whiten more patients and to attract new patients with whitening.
How do you remind your community that you are the one to come to for professional, safe, fast, and effective tooth whitening?
First, prop your reception room early with evidence that you are a whitening dentist. Remember that not all dentists do whitening, so this special season could be your opportunity to attract new patients — who just might stay with you when the season is over.
Second, try a Holiday Special! Your objective is to get the word out, and your solution is to start a buzz among your current patients. Just telling patients to pass the word about your holiday special to their network of family and friends can produce surprising results. A special is a good call-to-action to use in everything from a holiday newspaper ad to a statement stuffer.
Examples of good whitening specials include:
* A Two-for-one – Bring a friend and bleach the friend for free.
* A % Off – Provide a coupon for 10% to 75% off your usual whitening price.
* A Package – Bundle whitening with a cleaning and/or a checkup — great for attracting new patients.
Start making plans now and help more patients have a whiter holiday!