Benefits and Implementation: In-office Treatments, Hybrid Whitening Systems & Take-Home Methods.

According to polling data, the number one requested dental service from a patient to their dental office is for Chairside Teeth Whitening.

Unfortunately, this in office whitening service is a challenge for dental professionals to implement. So much so that entire stand alone “Teeth Whitening” businesses have been established in locations separate from dental practices.

Dental practices are responsible for their patient’s oral health and cosmetic appearance. Essentially teeth whitening should be used by all dental practices for most of their patient base. 

So why the angst to get started?  As a Doctor we get so much messaging from companies that we really don’t know what to choose and end up avoiding teeth whitening all together.  

Let’s break chairside bleaching down into four simple categories

  • Cost
  • Ease & Efficiency (Time)
  • Sensitivity & Pain
  • Maintenance

These four elements are the key when determining which patient recommendations your practice should offer. 


Cost is important as it relates to your bottom line and patient affordability.


Ease & Efficiency going to be the most significant aspect when it comes to office team acceptance and use.


Sensitivity & Pain is primarily felt by the patients. Offices will have to carefully navigate this aspect of whitening per patient.


Maintenance has a lot to do with results (short and long term) for your patients. 


Reviewing these each in detail will help you make the right choice or choices for you practice. The systems outlined below are not exclusive and can be used alongside one another for more patient options.

In-Office Whitening: Practice & Patient COST

This is a good place to start. 

We will discuss the more expensive version first.

We have all heard of expensive of in-dental office whitening procedures that involve a lot of money, a lot of chair time and a lot of patient sensitivity (pain).  

A typical ZOOM procedure cost $500, takes at least two hours in a dental chair and has considerable pain ramifications for patients after the procedure. 

This version of in-office treatment also comes with additional costs of chairtime and inventory replacement costs. This can be $100 to $150 per patient. 

On the lower end of cost are over-the-counter whitening solutions.

We are all familiar with Crest White Strips. This would cost patients about $50 a box for the strips, they are easy to use and can work but ultimately take too long and require too much patient compliance.

Other pricey options to chairside whitening procedures. 

A common alternative are custom tray solutions. Patients have custom made bleaching trays made by their dentist.  They will then buy whitening gel, place the gel in the trays and repeat this procedure over many weeks at home.  

Opalescence is the most common form of this type of whitening method. 

This procedure is typically around $350 and requires two separate dental office visits.  Oplescences is a common brand.

Another custom solution is called KOR.  It is very effective but costs a patient around $2000.

Value added combination chairside solutions (hybrid systems)

The combination of an in-office procedure coupled with a take home solution are value added teeth whitening methods.  These In-office treatments take around 20 minutes and provide a take home tray with pen for continued maintenance.  

The Smile Perfected hybrid whitening system costs dentists $997 and the light is free. 

The procedure is typically done at the same time as a patient’s 3-6 month hygiene visit.  Patient cost that receives the most acceptance is at $99.

In-Office Whitening: Practice & Patient TIME

Most patients think of “cost” purely as the cost of the whitening procedure.  

The definition of cost needs to include the patient’s and office team’s time as well.  

This makes sense and is only fair when comparing cost among the different options.  Both the patient and operatory time have real value.  

Time consuming Chairside Systems:

Imagine losing 3 hours of your workday getting a ZOOM whitening done. Practice owners are not thrilled when team members miss nearly half a day of work for one procedure.  

Moreover, patient’s are forced to spend valuable vacation time for an elective dental procedure. Time consuming chairside whitening treatments have a negative effect on patient acceptance. 

With that being the case faster and less effective retail treatments are looked for by your patients. 

OTC Whitening Options

Retail options are the fastest when it comes to a patient’s time.  You purchase the strips at Walgreens, CVS or Costco. A quick and easy purchase when considering time. The downside is the lack of results quickly.

Another thing to consider is that multiple OTC treatments will be needed to see bright and whiter teeth. This requires patients to purchase OTC whitening strips over and over costing them more time and money.

Custom Tray Alternative

Custom trays involve two separate dental office visits.  Although each appointment is typically less than 30 minutes, you still have to include patient and an auxiliary’s time.

Since custom trays require impressions or digital models remakes are not uncommon. Remaking and adjusting appliances requiring more office time. 

Once the fitting process is completed custom trays will fit perfectly. This will allow for higher patient compliance for at-home use. 

Hybrid Whitening Systems

Finally there are hybrid (combination) 20 minute in-office whitening systems.  

Patient’s are going to the dentist/hygienist every three-six months for re-care visits. 

Adding an additional 20 minutes to a dental cleaning is easy, cost effective and does not require a significant amount of time.

As this prophy-plus whitening procedure is taking place, auxiliaries can finish patient notes and begin cleaning/preparing for the next patient. 

Hybrid chairside whitening systems should come with a patient take-home option. Ideally, with a generic at-home tray that does not require impressions or custom trays.  

Both the in-office and take-home kits make-up an efficient whitening system offices can deploy with great success. Saving both patients and dental teams significant time. 

Beyond time, another aspect of chairside whitening offices need to consider is the patient’s pain and sensitivity. 

In-Office Whitening: Practice & Patient Sensitivity

Pain, sensitivity and irritation are common with every type of teeth whitening method. The reaction level to each depends on the physiology, condition and oral health of the patient.

Defining each (pain/sensitivity and irritation) for the patient before offering any whitening procedure is the most effective way to avoid patient satisfaction issues. 

Pain & Sensitivity associated with caustic office whitening 

The pain and sensitivity associated with more expensive, highly caustic and time consuming chairside methods can be described as a deep tooth pain and soreness. Commonly referred to as “Zingers”. 

Patient’s will describe two forms of sensitivity:

  1. Zingers – Bursts of extreme tooth pain across the entire arch. 
  2. Soreness – A lingering sensitivity similar to soreness after ortho treatments.

This happens because the method of whitening puts the teeth in shock. 

Teeth are extremely white, unnaturally white and dehydrated. Most offices prescribe higher strength Advil to alleviate the patient’s pain. 

The gels are so strong they require gum barriers and dental dams.  Time consuming procedural add-ons for the dental team.

Post procedure:

Dr. Balanoff Tip: Prep patients beforehand by telling them

  • We remove all of the soft tissue protection and instruct you that it is common to feel “zingers” or electrical shock waves through your teeth for the next 1-3 days.  The “zingers” are so intense that they will stop you in your tracks.
  • We would also tell patients that their brighter and whiter smile will begin to dramatically fade away after a few days. This requires follow-up and maintenance which is typically required. Additional costs and office visits are also a possibility.

Some patients still go through with this type of treatment even after the office warns them of the pain. 

Their smile becomes extremely white for a short period of time, but rarely are patients unaffected by the extreme stress put on the teeth using this method.

Dentists and auxiliaries are caregivers and do not want to hurt patients. They seek other forms of whitening that produce no pain and good results.

Hybrid systems and OTC products contain less caustic gel and produce results without pain.

Irritation of Soft Tissue during Teeth Whitening 

Irritation of soft tissue can occur with any type of peroxide used for teeth whitening. 

Typically this does not occur with higher concentrations (over 25% HP) of hydrogen-peroxide because blocking-out of gum tissue and dental dams are required to avoid severe burning.

Some patients have a high tolerance to stronger forms or gel while others can not handle even the lightest versions. 

When less intense gels are used irritation can occur. This may include blanching of the gums. 

Blanching is a completely normal reaction and will typically dissipate within 24 hours.  Patients can rinse with warm salt water for relief.  

Other irritation of the lips can also happen. Minor swelling can occur but will disappear within 48 hours. Additional Vitamin E and lip balm is an effective remedy.   

This shows the importance of applying enough Vitamin E before and during the hybrid system treatments to help avoid this reaction to teeth whitening.

The key is knowing your patients physiology and this further demonstrates the importance of having professional teeth whitening done in a dental office setting.

The best hybrid bleaching systems for no sensitivity offer both in-office non-caustic geld combined with a low grade gel take-home safe option.

This offers results and whitening maintenance in a natural healthy way without causing sensitivity. 

Other take-home options like white strips and other similar products are a great at-home teeth brightening choices.  

In order for these companies not to burn your gums they use an extremely low concentration of whitening gel.  Whitening is predicated on how strong the gel is how long you leave it on the teeth.

When using really high concentration of whitening gel you can leave it on the teeth for a short amount of time but you will hurt the gums and teeth. 

Office therefore recommend a really low concentration like whitening strips to avoid oral irritation and sensitivity. Unfortunately, this requires constantly reapplying the strips over many weeks or months to see any difference in your smile.  

The strips work, but there is no instant satisfaction or short-term result using this method.  For disciplined consumers or ultra-sensitive patients whitening strips are a great option Offices should inform patients that good outcomes will require a lot of patience and time.

Whichever option dental teams recommend and patient’s choose, one of the most important keys to successful patient outcomes is maintenance.

In-Office Whitening: Practice & Patient Maintenance

If patients want to keep a brighter and whiter smile they need to consistently maintain it.  What does that mean to both patients and dental practices?

Dental offices should look for a system that provides both in-office whitening and take home maintenance.  This allows for the office team professionally whiten teeth and still provide patients with a take home whitening maintenance plan.

One of the most difficult aspects of dentistry to successfully complete is higher patient compliance. By providing your patients with a take-home whitening plan the onus is on them to maintain their bright smile. 

Patient’s smiles will fade back to their original dull color. Continued application of either carbamide peroxide or hydrogen peroxide is required to preserve and enhance patient whitening satisfaction.

One drawback of painful whitening systems is patients are in such pain afterwards they don’t even want to talk about maintenance.  

Zingers subside and their smile fades back. Patient satisfaction is low and the discussion about their “dull again” smile begins anew.  

The smile maintenance discussion now turns to custom trays for difficult and expensive at-home options.  

Depending on the level of dissatisfaction offices should determine if charging for custom tray fabrication and at-home whitening gel syringes is necessary. 

Opalescence and Zoom take-home options can be an expensive giveaway.  

Patients are instructed to use the trays everyday for one hour until they run out of syringe gel. Once the gel is exhausted they should return and buy more syringe gel.

Maintenance with whitening strips is easy much easier. Office can instruct user to keep buying whitening strips at $50 per box. This can go on for a long period of time and offices are turning away a much needed source of revenue. 

Hybrid chair-side whitening maintenance is every three days and the syringe or pen gel is painted on the teeth. Hybrid teeth bleaching systems should come with a generic silicone tray which can be used in-office and at-home.

Custom tray fabrication can be done but adds unnecessary time and cost.  

With combo whitening systems there is no waste and it is very easy to use.  A single syringe or whitening pen should last 30 applications or 90 days. Perfectly timed for patient recare visits. 

Office only have to recommend a few basic things to ensure patient satisfaction when it comes to brightening and lightening teeth. 

  • Avoid food and beverages that stain like coffee, tea, wine, sports drinks, hard candy, berries and tomato sauce based foods.  These food and beverages will stain and discolor your teeth and require more maintenance. 
  • Use a paper straw.  Straws are very effective keeping any drink off of your teeth.
  • Quit smoking. Easier said than done for most.  E-Cigarettes and smoking cessation programs are getting better everyday. Use teeth whitening as one more reason to quit. 
  • Combine take-home gel with whitening toothpaste.  The jury is still out on the overall effectiveness of the whitening toothpaste but there is no danger is combining both.

In-Office Whitening: Outcomes office should consider

Overall dental practice need to consider all options when it comes to teeth whitening. Especially since it is the #1 request dental service and patients prefer to have it done in a professional dental setting.

Dentists want to give patients an illuminating smile. To successfully accomplish this dental offices should consider four aspects:

  1. Cost…Office systems can be expense for dentists and patients. Choose one that fits your budget and affords your patients the opportunity to say YES.
  2. Efficiency of Time…Will this system fit into our current workflow and be accepted by the dental team and patients.
  3. Sensitivity and Pain…Are patients going to be hurt will this cause unnecessary stress on the practice team. 
  4. Maintenance…Patients need a solution that will last and the office team needs to promote patient compliance for better overall oral health and whiter teeth. 

In the end, dental practitioners should consider multiple options to ensure they meet the needs of their patient demographic. Because…

  • All whitening systems work to make teeth brighter and whiter.
  • Some whitening systems can cause a lot of pain and sensitivity and produce unnaturally neon white teeth.
  • Over-the-counter solutions are in-effective but cause no sensitivity.
  • Ease of use and cost of maintenance is a major factor when considering in-office whitening options. 
  •  Dentist and dental teams should not go down the path of whitening unless they are committed to whitening.
  • A hybrid system which offers chairside whitening with an at home maintenance program should be at the forefront of every offices business map.

Choose Whitening systems that give your patients options. These options need to keep them and your office team happy to be implemented properly

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058574/

https://www.science.gov/topicpages/t/teeth+whitening

Author: William L Balanoff DDS, MS, FICD

Dr. William L. Balanoff graduated from Northwestern University and received a postdoctoral masters in cranio-facial research from Nova Southeastern University. Dr. Balanoff practiced clinical dentistry for 30 years. He was on staff at two hospitals in South Florida. Dr. Balanoff has taught at numerous academic institutions worldwide. Dr. Balanoff is published and sits on two different peer reviewed journal editorial boards both in dentistry and medicine. Dr. Balanoff has testified before the US Congress and helped craft public policy initiatives in the US as well as Russia, the Ukraine, Belorussia, Japan, Spain and England. Dr. Balanoff holds a number of patents for unique medical devices. Currently Dr. Balanoff is a science consultant for Abova Health and is the CEO of Oral Care Perfected. Dr. Balanoff has appeared on the CBS show “The Doctors” for his groundbreaking research with respect to an oral appliance mitigating the motor and vocal tics associated with Tourette Syndrome.