Dr. Gerard Kugel Talks About Tooth Whitening: In-Office, At-Home, or Both?

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. For most of us, tooth whitening has become a fairly easy and routine procedure. And on top of that, it's one that is rewarding and profitable. Nevertheless, new systems continue to be introduced into the marketplace. And that has us asking ourselves, should I be doing chair-side whitening or perhaps shift my patients to using take-home bleaching systems? Will I get better results by using both? Do the over-the-counter whitening products work? And if so, how do I incorporate them into my clinical practice? To help us answer some of these questions is our guest, Dr. Gerard Kugel. Dr. Kugel is an Associate Dean for Research. He has published over 120 articles and over 300 abstracts in the field of restorative materials and techniques. He lectures both nationally and internationally and is part of a group practice, the Trinity Dental Center, located in Back Bay, Boston. Dr. Kugel, it's a pleasure to have you on Dental Talk. Phil, good to see you again. We go back many, many years. Yes, we do. So it's good to see that you're still practicing, still teaching. It makes me feel like I'm not the only guy that's hanging on for a while. We've been doing this quite a while. It's been decades. I'm very grateful and we're healthy. That's what counts. Yes. So when it comes to whitening, how does one decide if in-office whitening is best for a patient when there are so many products available over the counter? You know, in the old days, when we didn't have so many products, it was easy to talk to a patient about whitening. Now, the issue we run into is with all these options and choices to make, we've got to be, number one, honest with patients. And there are a lot of products and, you know, hydrogen peroxide whitens teeth. So it depends on how they want to whiten, if they want to do it at home, if they want to use a... a strip if they want to use a pre-loaded tray um so i think on my end i never tell people there's something a take-home that's better because there's so many take homes i always tell them to be careful with the take -home products for instance because a lot of them don't have a lot of evidence so if you look at take-home products there's not data on them um you know they don't do research uh there's no safety data I'm assuming most of them are pretty safe. So I tend to tell them, you know, if you want to whiten, you can do something that you buy at a store, you know, or get online, or you can do it in the office. And the beauty of doing it in the office is we help you. We understand any side effects or problems. And last but not least, you warn them that if they're going to whiten on their own, let me know as the practicing dentist, because if I need to do a filling on you, I want to know that you plan on whitening because my filling won't change color. There are some now of these chameleon composites, and they do change color because we've tested them, to be quite frank, when you whiten teeth. However, depending on where the filling is will really depend on how much change you get in the restoration color. So the point is, make sure the patient knows if they're going to do it on their own, they let you know what they're doing. But I do try to push them into doing something in the practice. Those are good points. And that's a whole nother podcast is talk about these direct restoratives that have that chameleon effect. Regarding in-office whitening, I know in the past we've talked about this offline. You're a big fan of in-office whitening. It kind of depends on your practice and how you do things. But in your opinion and your decades of experience in this, what are the top three reasons you prefer in-office whitening over any other method of whitening? Well, there's a bunch of reasons. One is the patients that I deal with. practice. My practice is on Huntington and I have in downtown Boston or across from Copley. We have a pretty high-end patient population. Remind me to tell you a funny story about whitening and helping the needy, but we have mostly high-end population, a lot of executives, business people, and they're like, Doc, I'm not going to wear a tray. I just want to get whitened. Can I do it? Can you help me? So we do a lot of Zoom. In the old days, I wasn't as big a Zoom fan prior to their, you know, Philips. changing the light technology and making it a little different with the led lights they used to use metal halide lights and we get a very nice result we do tell the patients we can do the end office and that's when we chose in our practice it'll be quicker i call it a jump start i always tell them they still need to do some touch-up we either give them some adjunct like a whitening pen or we usually make them a tray tell them that they're going to have to touch up at some point. So for patients that are on the go, patients who just don't want to sit with a tray, the other one is somebody needs whitening fast. They're going to be, I have a couple of clients who are on TV and one of them said to me, look, I'm going to be interviewed on CNN. I want this done quickly. I said, let's zoom whiten you and then we're going to give you a tray. You can do some touch up. They were happy and it was a very effective procedure. So patients and the types of patients you're dealing with. the wow effect. Another thing I do a lot with our whitening, so I'll give you an example. One of my patients who's been with me for years was getting married, a young girl, but been with me five, six years. Parents were my patients. She said, oh, Dr. Paul, I'm getting married next week, and I wish I could do the whitening, but with all the money I'm spending, and I said, I'll tell you what, it's my wedding present to you. I said, well, whiten your teeth, and it's on us. I have a... Guy at the restaurant that I go to, and he and his partner are going to be getting married this summer, and Dr. Anderson, who works with me at practice, we said to him, James, come on in, both of you guys, before the wedding, and we're going to whiten your teeth. It'll be our wedding present to you. Don't think I'm stupid. I never have to wait for a table. Is that the funny story you wanted me to remind you of? Oh, so the funny story is I work with the homeless vets. Yeah, I'm glad you reminded me. That's why I told you to remind me. I'm too old. My memory is not what it used to be. So we work with homeless vets. So I go to a vet shelter, and we have vet Fridays in our practice. So a couple of times a month, we'll bring vets in and treat them. The dental school has a vet program that I'm involved with. A lot of homeless vets. So I go to the vet center in Brighton, Brighton Marina, and I'm screening patients. And there's a guy who's in his 80s. He's a vet living at this low-income housing unit. And I said, his teeth look pretty good. So I said, Ed, what is it you want? He goes, I want white teeth. He's 82. I said, why do you want white teeth? He goes, I've never had white teeth. I've always wanted them white. I said, that's what you want. So I said, I'll tell you what. This is easy for me to do. So that's what the beauty of whitening. It's easy. My staff does most of the work. I just come in and say hi. And I check on them. I tell them what's going on, whatever. We bring them in. Teeth are all a little bit gnarly. I recontour them for about 20 minutes. So I get rid of the rough edges. I round things off. We put them in the chair. We zoom whiten him. While he's in the chair, we made some trays for him to take home. I have never had a happier patient. I got a vet living in a low-income housing shelter. I recontour his teeth. I did one composite on him, which was easy, and I whitened him. And you would think that I had just bought him a new car. He was the happiest guy. The satisfaction you got out of that was probably, not probably, but worth way more than the money someone else would have paid you for it because that would have gone right into your bank account and you would, just like another patient. no it's really amazing uh you're giving back to the community so this guy's walking around at 82 years old smiling all day long and the recontering it sounds funny i you don't always have to grind a tooth down to make it look better sometimes just you know you have that worn a little bit of worn edge with that You know, rough enamel, rounded it all off, smoothed out his teeth, recontoured some line angles, made them look straight, whitened them. I didn't do anything that any dentist couldn't do. I think he has an 81-year-old girlfriend in that facility that he's not telling you. You may be right. Let me ask you this. Is the fast-acting process of whitening the teeth, in your hands you use Zoom from Philips Oral Healthcare, there's other systems out there, because it's so quick, is there any side effects? that the patient should be aware of versus a slower, more gradual process with the take-home systems? It's a great question. And take-home, they work fine. So I don't say to a patient, you know, I don't... believe and again this is my opinion i've done a lot whitening that when you do a chair side whitening you're getting a better result you're getting a faster result if you take a tray you're going to get white you know you get to a certain level and then you plateau you get a little bit of rebound i always tell people that and we published on this years ago so um my my point is that the problem you might have with a chair side whitening sometimes people can be sensitive their teeth dry out a little bit they can be sensitive to whitening anyway but Probably about half your patients have some sensitivity, whether it's take home or chair side. I think the way they've done it now with the new lights where you can adjust the intensity, the LED versus some of the other light sources they used, you still get sensitivity, really not so much with the teeth. Where I see more sensitivity is with the soft tissue because sometimes if your assistant doesn't do a great job isolating the soft tissue, you'll get that tissue burn from the peroxide. That tissue burn will go away. usually within 24 hours, actually sooner than that. And it's always the story. I talk to you offline a little bit about this. One of my friends, who's a PhD, and Dr. Anderson and I, friends of ours, we go out for drinks with him sometimes. Nice guy. Point is, wanted his teeth whitened, we offered to do it for him. He said, come on in. And the biggest side effect he had was he had a tissue burn in his papilla between eight and nine because the liquid rubber dam hadn't been sealed well enough. That is a big side effect, sometimes tooth sensitivity. You can also get tooth sensitivity with tray whitening. I believe it's mostly dehydration. So either system can cause sensitivity. The whitening chair side, you always check between applications and always have somebody there because the mistake people make, and I had a young dentist do it in my office. She left somebody in a chair, had the assistant leave. In the back of the office, we have seven chairs, and the guy was having a lot of pain. and then complained later that there was nobody there so when he had pain to let them know and the pain was again on his soft tissue so i bring this up because i don't think there are many major side effects there are no documented long-term negative side effects with whitening we used to do a lot of safety and efficacy in the old days whitening with trays and with lights and we never had never had any long-term issues we were i mean my endodontic friends in the old days years ago in the middle 80s when we started to say, oh, we're going to be root canaling all those teeth. Well, that never happened. So what about the enamel, the actual integrity of the enamel itself? We've tested that repeatedly. Matter of fact, you never see articles on it anymore because the micro hardness studies we did on enamel, we never had an issue. And in the early days, the only issue we ever had, and it was funny, it was a study I published with Dr. Jonathan Garlick and a few other people, and it was a tissue engineering study showing long-term exposure of peroxide. on soft tissue it was a 3d tissue model we did in a tissue engineering lab here we found it changed this the dna in the cells putting them in the direction of a of a carcinogen but that was very long-term exposure and it wasn't tooth it was soft tissue and it was not in the mouth it was done in a lab so you know i guess the argument could always be any any overuse of anything that's my argument so if anybody abuses whitening then they're out of the realm of of what we know or should be dealing with. And I'm sure there are people who have used whitening products. But even those patients, and I've seen one or two in my lifetime, I haven't seen any major. Yeah, those are like whitening addicts, right? They're just coming in for weeks. They have a cup of coffee and they'll run into your office to get it whitened. Yeah, let me ask you the question. No, I know they are. So if we're doing in-office whitening in a practice, should we be incorporating take-home bleaching systems as part of the overall treatment? I think yes, or some other touch-up system, because the data is pretty clear-cut. You will get white, but you will rebound, and everybody's different. So for me to predict how much rebound one person will have, now, when I say rebound, you'll get to a certain level and same thing with trays you stop whitening with a tray everybody drops off that's one of the reasons when you do in office or take home whitening you always say to your patient before you come in for me to do those crowns on seven eight nine and ten um i need you to stop whitening i tell them for two weeks before you come in one reason is they rebound so i'm going to take a shade the second thing is you don't want to bond to teeth that would just whiten because the oxygen the oxygen free radicals interfere with polymerization so one reason is if you're going to use a resin cement you don't want to be using a cement on somebody that just whitened a resin cement and secondly you want to get that rebound so i think giving them an additional take home um i know phillips came out with a system called zoom delivered which is an interesting one you can do a digital scan but you really need to have a scanner you send it to one of their labs they will for for a relatively well it's very low cost i think send the patient directly or you if you choose the trays and the gel with instructions for whitening or you can make them in yourself in the office or we were at one point giving a whitening pen for a touch-up but that's not as effective because the percent peroxide was a little bit lower so a combination is a good option you don't have to do that but I think you should secondly if I'm doing crowns on a patient I always tell them you're gonna have to titrate your color over the lifespan of those crowns because You and I both know I'll do those crowns. They'll get white. They're happy. It's a B1. A year later, they drop a little bit. Maybe they're, you know, A1, B1. I tell them they may want to touch up. It may be one day for every week they bleached. And that may be every one or two years they want to do a touch up. Warn them not to overdo it because the same story occurs. You can make the teeth much whiter theoretically than your crowns. So the only issue you have when people are combining restorative with whitening, they're always going to have to worry about, balancing the color of the crowns to the teeth. Yeah. Now, what about when a doctor is doing a veneer and the tooth structure that they're putting the veneer on has some stains in it intrinsically, maybe extrinsically? What's your process as far as whitening prior to delivering a veneer? Yeah, it's funny. So it's funny, Brian. It's a little related. I'll get back to the veneers. One of the things I do a lot of is micro-operation. with, it used to be hydrochloric acid and pumice, Ted Kroll, a Pennsylvania guy. Pediatric dentist. Super guy. And Ted published years ago, 86 or 85, 86, on using 18% hydrochloric acid and pumice to remove white spots, hypocalcifications. I do a ton of combined white spot removal, post orthodontic. I have one kid, I published it, such dramatic change. I got rid of all his chalkiness on all his teeth. The same day, because he came from out of state, we put him in a chair, we zoomed, whitened him. And when I showed the picture, well, when we were done, my dental hygienist did the whitening. She was photographing it with her iPhone, sent it to a dentist she works with on Fridays. And that dentist said, I don't believe that photo. It looks like it was doctored. She writes back, I took the photos and they are not doctored. So sometimes, you know, and he came from veneers and that's part of the story. Young guy. A teenager, 18 years old, wanted veneers because he had those chalky white spots. So I micro-abrated him. I whitened him. I gave him a take-home tray. We never veneered him. So that might be your first shot. Which is great because the last thing you want to do is start taking off enamel on a kid that's 18 years old. Exactly. And the orthodontist purposely sent them to me because he mentioned to me, the orthodontist who referred him, see if he can get rid of those white spots. He wants to get veneers, and his parents were pushing for that. So sometimes something that simple gets me out of veneers. I've done as many veneers as anybody in the world, but I find myself trying to not grind down too structured if possible. So if I can whiten, recontour, or get rid of white spots, I may not even need to do veneers. So that microabrasion, what's the chemical ingredients in that? It's HCL. So normally if you're pH-ing in a pathology lab, you're using 36%. In the old days, in the 80s, I would dilute it myself one-to-one with water, put it in a thick slurry of pumice in a glass daffin dish, and I'd take a cotton swab, five seconds, and rinse. Now you can buy from Ultradent, for instance, Opal Luster, which is pre-made. You're basically removing superficial enamel. Hypocalcified tissue, demineralized, will remove more quickly than healthy enamel. So you only want to do a couple of five seconds, stop, rinse, five seconds. I rubber dam them. After they're done with that, we rinse it all off. They're a little dehydrated. We put the liquid rubber dam on. We put the ring in and we do the whitening. And that's usually, that's a real wow effect for people. You always tell them after you're done, they may look a little chalky still because they're dehydrated. You know, Ted Kroll calls those ghost white spots, meaning that if you had those, Phil, and I got rid of them, and I do so much of this, it's scary. And whenever I lecture and I show it in one of my lectures, and it's usually part of another lecture, the most questions I get is on that. Yeah, I believe it. I believe it. Yeah, it's a miracle worker. That's what you are. You do something like that. And on those cases where, you know, why would I grind those teeth down? And again, recontour. Sometimes I just recontour. I micro braid and I wait. If you do veneers, though, it's not a bad idea to wait first. But the beauty of veneers, I joked, I just did Monday, seven and 10 and 20, 23, 24 on a patient as crowns because they were rotated and she's on TV. And I said to her, you know, dentists don't like doing what I'm doing. Think about it. laterals and two of the anterior teeth there. It's tough for the color match, but I didn't want to grind down healthy teeth and she really didn't need them. She was very grateful, but I said, dentists have a much easier time doing eight crowns or eight veneers. You're doing two veneers. It's a nightmare because you want to match color. So I would prefer not to do the crowns or veneers if possible. And she actually originally had thought she would need more, but I did whitening. We zoom whitened her. We micro braided her. I recontoured, so we went with only the rotated laterals and two crowns on the lower. Nice. Really top-notch, conservative dentistry, happy patient. Let me just ask you about whitening toothpaste, since we're on the topic of whitening. In your opinion, are they overrated? Do they make a perceivable difference? Do they work? They are a bit overrated. They work depending on how you define work. And I'll tell you a little anecdote, and I'll try to make it quick. I won't tell you the players, but the Federal Trade Commission. hired me a couple of years ago as a consultant on a case regarding whitening toothpaste. One of the major players was saying our whitening toothpaste will change tooth color two to four shades. My job was to review the literature for the FTC to see whether or not this was real and the advertising. And the reason it was interesting, I had not read as many of these papers as I had to in this case. At the end of the day, they had data to show average was really more like two shade changes but they had up to four shade changes in some cases now if i remove stain on your teeth if i remove plaque i can probably get two shade changes so some of those whitening toothpaste are probably doing a better job just cleaning your teeth because they don't care as long as the shade changes and it was funny i went back to the federal check commission i said guys the company's data does support their claim whether you want to believe it i mean it looks like it was it was okay data you're going to have a hard time going after them. The whole thing backed off because they said, okay. I bring it up because that made me believe, okay, whitening does have some effect, those toothpaste, but if you think you're going to be an A35 shave, grab one of the whitening products, toothpaste, and you're going to suddenly look in the mirror and say, wow, it ain't going to happen. Maybe as an adjunct, do the chair side whitening or the take home. whitening toothpaste i guess yeah um so my answer is a mild yes but not a real hearty yes i'm not jumping on those whitening right so it's a little bit of misleading advertising on the standpoint from the standpoint yeah if you look at the people they do of course they're advertising i get it we'd be doing the same thing they have a model with with you know bleach white shade already you know whiter than a b1 smiling you're assuming that came from a toothpaste no that male or female had that tooth color before they got into the commercial So those toothpastes are a little bit misleading. I'm just happy if you're brushing the regularly flossing and using any fluoride toothpaste. I'm a happy guy. If you want to throw a whitening toothpaste in, sure. Most of them are not that abrasive. In the early days, some of them were pretty abrasive. All right. Well, listen, Dr. Kugel, it's been amazing having you as usual. Always enjoy interviewing you on the show. You get incredible viewership when we put you up there. So you're a celebrity. You're a rock star. Enjoy Boston. to your team out there, but we'll see what happens. Yeah, I'm not holding my breath on that one, but yeah. I don't know if you want him anymore. He deserted you guys. You think we're going to say no? What, are you crazy? Yeah, right, exactly. All right, you have a good one. Thank you so much, and enjoy the rest of your day. Take care, you too. Thanks for everything.