MANAGING AND DEVELOPING A SUCCESSFUL WHITENING PRACTICE

Linda Greenwall

INTRODUCTION

Tooth whitening has become one of the treatments most requested by dental patients. Dentists should ensure that they are knowledgeable about the full range of whitening treatments available to patients and should know how best to deliver these. Now that the legislation on whitening has been amended, it is very clear which whitening treatments can be undertaken in an effective way. Furthermore, tooth whitening is the practice of dentistry; therefore only dentists and their trained teams may undertake this treatment for patients, after performing a thorough assessment of the suitability of the patient to undergo the whitening treatment. This chapter will explore ways to develop and manage a successful whitening practice in which whitening is the beginning of the treatment plan and further minimally invasive treatments can be undertaken. This knowledge will help dentists run and manage a successful whitening practice with the full dental team engaged to assist with all aspects of whitening.

Developing and managing a successful whitening practice (Table 23.1) can be achieved with the use of 15 strategies (Table 23.2).

STRATEGY 1–LISTEN

“First seek to understand, then to be understood” (see Covey 2004).

Before undertaking any form of esthetic treatment, it is essential first to understand what the patient is requesting (see Figure 23.2 and Table 23.3). Patients who have seen television makeover shows may think that chairside treatments can be undertaken in 20 minutes during a lunch break. Many of the treatments take much longer, and patients need to fully understand what is required to achieve a significantly lighter shade. A commitment from the patient is essential. Some patients may have unrealistic expectations of the desired outcome. There exists a quest for unrealistic white shades such as the Hollywood white shade, which may be impossible to achieve with home whitening, and this should be carefully explained to the patient before the start of treatment. Full explanations should be given to the patient once he or she has clarified the request for whitening treatment.

STRATEGY 2–CLASSIFY THE WHITENING TREATMENTS (SEE Table 23.4)

There may be several reasons for the discoloration that the patient is experiencing. It is essential that the dentist diagnose the reason for the discoloration because this will affect the outcome and the length of time that it will take to complete the whitening treatment. Not all whitening cases are the same. Classifying whitening treatments based on patient need will help with planning, staging, sequencing, and fee setting for the different types of discoloration and whitening treatments. It will help with determination of the correct appointment lengths and types. Once the procedure analysis of the whitening appointments is completed, then appropriate fees can be set.

Treatments need to be classified because the treatment times and fees are different for a basic case versus an intermediate case versus an advanced case. More whitening materials will need to be supplied for advanced whitening cases. A basic whitening case requires no restorative dentistry and will take about 4–6 weeks to achieve a B1 shade. An intermediate whitening case normally involves two whitening treatments, such as internal and home whitening (see Table 23.4). An advanced whitening case involves extensive discoloration, such as fluorosis or tetracycline discoloration, and/or requires complex restorative dentistry. Whitening treatments in this category will take longer owing to their complex nature, so the planned sequence of treatments will take longer and the associated fees will be higher.

STRATEGY 3–UNDERTAKE EXCELLENT WHITENING TRAINING

Undertake training for yourself and the entire dental team. There is a vast body of scientific literature demonstrating the effectiveness of the whitening treatments that have been presented in this book (also see Greenwall 2001). It is essential that the dentist and the team understand the process of whitening and how it works and whitens inside the tooth. Tooth whitening has a scientific basis, and we need to further understand what the research demonstrates. Ensure that you are well trained in whitening techniques. Attend seminars and obtain hands-on training on whitening.

STRATEGY 4—CONTINUALLY UPDATE YOUR KNOWLEDGE OF WHITENING

Update your knowledge as the regulations change and new materials and technology are introduced. It is essential to keep up-to-date because many new products enter the market with different modes of action and treatment times.

STRATEGY 5—LEARN TO PLAN WHITENING TREATMENTS EFFECTIVELY

Plan treatments effectively so that the results remain sustainable and long-lasting. The protocols that were established by Haywood (2003) have been shown to be effective. Patients cannot be given the whitening trays and gel and then be left alone. They need constant monitoring and motivation to continue the treatment effectively. It is essential that the home whitening treatment be broken down into small, manageable stages so that the patient can comply with the treatment recommendations and the dentist and hygienist-therapist can monitor the patient well.

When planning all dental procedure for patients, it is important to categorize the type of procedure that will be undertaken and to assess whether this is a primary, secondary, or tertiary appointment. A primary appointment is one with a high value in terms of revenue (Tables 23.5 and 23.6). A secondary appointment is one that has a lesser value but still involves essential dentistry. It can be important and urgent. It covers a lesser fee in terms of production than a primary appointment. A tertiary appointment is the lowest value appointment; it is still important. It is a shorter appointment and does not normally command a fee. These appointment categories are preblocked into the schedule for the year so that every day, primary and secondary appointments can be scheduled. This helps with efficiency, stress management, and planned practice production.

STRATEGY 6–MANAGE COMPLICATIONS AND SENSITIVITY ISSUES THAT PATIENTS MAY EXPERIENCE

Up to 85% of patients experience some type of sensitivity during the whitening treatment. This may be a result of the material penetrating the pulp within 5–15 minutes of gel application or tray pressure, the application of the higher strength materials, or toothbrush abrasion. Sensitivity is a major side effect and should be well managed (Browning et al. 2007) so that the patient knows what to do if he or she experiences it.

STRATEGY 7–SUPPLY EXCELLENT PROFESSIONAL WHITENING MATERIALS

There are excellent professional whitening materials on the market for dentists to supply to their patients. Many of these products have been carefully researched to show safety, effectiveness, and the long-lasting effect of the materials. Many advanced cases of severe discoloration such as fluorosis can be effectively whitened using low-strength whitening gels such as 10% carbamide peroxide materials (see Figure 23.6). Nonvital whitening can be undertaken only with use of 16% carbamide peroxide or no more than 6% hydrogen peroxide; dentists need to know how to apply these materials into the canal properly, how to place the intracanal dressings, and the length of time between visits.

The new regulations state that with each cycle of use the dentist should first examine the patient to ensure that treatment is appropriate for the patient. The receptionist can no longer supply whitening materials to patients for touch-up or maintenance treatment. Each cycle of use requires that the dentist perform an assessment first. This is to protect patient safety.

STRATEGY 8–ENSURE THAT PATIENTS HAVE WRITTEN INSTRUCTIONS

Patients must be given written instructions and must give consent when undertaking the treatment; they must know exactly what to expect, what will happen, and what will not happen (see Figure 23.5C). Explain the instructions verbally and follow up with written information so there is no miscommunication with the patient. This helps the patient to understand what is required of him or her and how to comply with the home treatment instructions. It is essential that patients know what they can expect in terms of the whitening result—what is likely to occur and what expectations are not realistic (see Figure 23.7).

STRATEGY 9–TRAIN YOUR ENTIRE TEAM ON WHITENING TECHNIQUES

The entire team should participate in training and programs so that everyone will be on board with the treatment that you are offering. Each member of staff can be involved in a different aspect of the whitening treatment. The receptionist needs to know which appointments to schedule for whitening and the cost and the time allocation for each whitening appointment. Every team member needs to help with the whitening treatment. Each team member also needs to know how to set up the tray for each stage of whitening and which materials to place on the tray. Team members can also help with marketing the whitening program to existing and new patients.

STRATEGY 10–UNDERTAKE TOOTH WHITENING FOR YOURSELF AND YOUR TEAM

It may be beneficial for yourself and your practice team to undertake the whitening treatment. It is essential that the team members, including the dentist, have a good white smile, which demonstrates the benefits of esthetic dentistry, especially when talking to patients. All staff members need to experience the whitening treatment themselves. If they experience sensitivity, they can empathize with the patient and offer advice on how to treat the sensitivity. This helps with management of the whitening program and communication with the patient.

STRATEGY 11–PLAN A WHITENING AND HYGIENE SERVICE FOR WHITENING MAINTENANCE

Many patients who are planning to whiten their teeth also want to have cleaner teeth. Patients should be actively engaged in a regular hygiene regimen. Patients may then choose to have a hygiene and whitening appointment in which the upper teeth are cleaned first, then the upper whitening tray is filled with a hydrogen peroxide day product. The lower teeth are then cleaned, and afterward the lower whitening tray is inserted with whitening material. That way the patients can undergo initial whitening or maintenance whitening and teeth cleaning during the same appointment. There are several different types of this service that can be designed. In addition, research has demonstrated that tooth whitening materials improve the gingivae (Firat et al. 2011) and reduce swelling, so a regimen can be undertaken that incorporates both treatments. In the study by Firat and colleagues, home and chemically activated whitening systems were found to be safer for tooth whitening and maintaining gingival health than a light-activated whitening system, which might lead to increased proinflammatory cytokines (interleukin [IL]-1β). Many patients would benefit from the use of whitening trays (renamed therapeutic trays when used for the purpose of not only whitening but also improving oral health for certain patients) and oral hygiene. Use of the whitening trays has demonstrated an improvement in the oral health of patients, including elderly patients (Haywood 2007) and special needs patients (Lazarchik and Haywood 2010).

STRATEGY 12–TOOTH WHITENING AS A BEHAVIOR-CHANGING EXPERIENCE FOR PATIENTS

Tooth whitening is a practice builder. The behavior of patients changes as they see the benefits of the whitening treatment. Patients are normally delighted with the results. They are walking advertisements for your practice. Ensure that all patients who have completed successful whitening treatments are given practice cards to give to their friends and business colleagues for referral.

When patients report how delighted they are with the results, give them a patient testimonial sheet to complete. Ask the patients for permission to put their testimonials on your website to further promote your whitening. This is very powerful to read for prospective patients looking to have whitening treatment.

Tooth whitening treatments can change patients’ lives and how they feel about themselves. Be part of the journey. It is a great experience and brings joy back into dentistry!

STRATEGY 13–MARKETING WHITENING SERVICES

Because whitening is one of the services most requested by patients, dental practices need to be prepared for questions from patients about whitening treatments. It is a good idea to prepare marketing literature, information leaflets, and answers to commonly asked questions about whitening so that patients have information to take away with them. Be ready to answer patient’s questions about whitening; this is a way to build the dental practice and expand the range of services. Special days can be allocated for whitening with the hygienists and dental therapists, such as Whitening Wednesdays. Special rates can be applied if a whole wedding party wants to whitening their teeth. It is essential to draw up a marketing plan for this service and all esthetic dentistry.

STRATEGY 14—WHITENING TESTIMONIALS

Patients really enjoy seeing the process of their teeth getting whiter. They are normally delighted with the results of having whiter teeth. They often express their delight with the shade of their teeth on the second visit during the whitening review appointment. It is a good idea to ask the patients to complete a whitening testimonial sheet. With their permission, this can be posted onto your website. My experience is that these testimonials drive patients to the practice, especially when they see the before and after gallery photographs.

Always give the patients extra practice business cards, because many of their friends and colleagues may compliment them on their new whiter smile, and the patients can be walking advertisements for your practice. Whitening teeth is a good way to build your esthetic dentistry practice and expand these services for your patients.

STRATEGY 15–SMILE BOOK

It is a good idea to collate a smile book of your before and after photographs, which should be standardized, showing a portrait of the patient before and after and a close-up of the smile before and after. You should obtain a signed photo release consent form from your patients so that these photographs can be used for marketing services and publication. If you are planning to put these on your website, you should use a special online publication consent form.

DEVELOPMENT OF A THRIVING WHITENING PRACTICE TAKES PLANNING

The dental practice should set a goal of improving its whitening services to patients. The patient’s journey should be fully understood before any planning meetings are conducted (see Table 23.3). Hold a team meeting so that whitening appointments can be planned. Whitening procedures should be documented and a procedure analysis form completed for all whitening appointments. Evaluate all whitening treatments that can be offered, and introduce some new whitening treatments as new techniques are offered. Plan each team member’s role in the whitening treatments provided by the practice; that way the dental team takes ownership of the new initiative.

GETTING STARTED WITH WHITENING

The aforementioned strategies should be planned in a systematic manner, then goals and plans should be established and activated according to schedule (Table 23.7). First, create the vision of how to deliver excellent whitening treatments for patients by developing an action plan.

It is important to ask existing patients open-ended questions, such as how do they feel about the color of their teeth, so they can discuss any concerns about their tooth shade (see Figures 23.2 and 23.4). Another way is to take current shades of the patient’s teeth at the examination appointment. This can lead to a discussion of tooth shade; the patient can be shown the normal tooth shade guide so that he or she can see where the existing shade falls (see Figure 23.5A). The existing shade should be documented in the patient’s clinical records.

Most patients would prefer lighter teeth. At the next appointment the patient may ask if the teeth have darkened, and this can be measured.

If new whitening services are introduced at the practice, information leaflets can be given to patients who ask about whitening services. A wide range of treatments is available for patients requesting whitening. Such patients may include adolescent patients who have noticed that their teeth have darkened after orthodontic treatment, during which there was food accumulating around the braces. In addition, patients who have just completed orthodontic treatment may require some minor esthetic treatment—for instance, improvement in the esthetics of peg-shaped laterals (see Figure 23.8). This needs to be carefully planned with the orthodontist. In fact, orthodontists may be an excellent source of referral for whitening treatments. Send your newly created smile book to 20 local orthodontists. That is an excellent way to receive new patient referrals.

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