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Perhaps there is no facet of modern dentistry that describes the "New Paradigm" of health care private practice as concisely as cosmetic dentistry. While the concept of rendering cosmetic dental service is as old as dentistry itself, the focus on appearance as the sole treatment objective is new. Savvy dentists have seized upon this opportunity to exploit the fact that it's easier to sell what people want than what they need. In so doing, the health care provider has moved beyond health care and into the territory of the cosmetician.

Q: What are the effects of whitening your teeth? Can it damage the teeth?

A: If by whitening you mean a dentist-administered bleaching treatment, it is currently thought to present little risk except for some short-term soreness of the gums and a transient increase in tooth sensitivity to heat, cold, contact, and sweets. It is a relatively new technology, and the long term cumulative effects, if any, are not known. This may be significant, since bleaching may need to be repeated at indefinite intervals to maintain the whitening. The same degree of safety cannot be assumed for unregulated over the counter bleaching agents, due to the unknown nature of their content.

A: Intrinsic stain (that is, discoloration of the tooth structure itself, rather than a surface stain) responds moderately well to bleaching. The difficulty presented by staining that results from tetracycline use is that it is not uniform, but usually presents as horizontal light and dark bands. For such teeth, the banding effect will remain after bleaching, albeit in a lighter color. The only practical way of eliminating the staining you describe is by covering it up. This can be done by the placement of crowns, or more conservatively by placing porcelain laminate veneers. I would advise your husband to ask your dentist about these options.

A: It is true that once bleached, teeth will eventually tend to relapse and darken. There's no reason why they can't be repeatedly re-bleached, but this is something you may prefer not to do. In any case, the bleaching causes only a modest amount of whitening, and the disparity between your new caps and the bleached natural teeth is not likely to be great even if the bleached teeth darken.
Do you think your natural teeth are too dark? This is entirely a subjective judgement, and your opinion is just as valid as the dentist's. If you like the color of your natural teeth, skip the bleaching, and just have your dentist match the caps to them as they are. This is the basis on which you should base your decision whether to bleach.

A: Intrinsic stain does not noticeably vary over short intervals; any change is gradual and usually escapes notice. If the stain you see is intrinsic, i.e. a staining of the tooth structure itself rather than a surface deposit of stained material, any changes you see are probably the result of some change in ambient lighting. You'd be surprised how important quality and quantity of light is in evaluating tooth color. It's an important consideration in dental practice, since dentists must frequently evaluate color and other optical qualities when matching restorative materials to natural teeth. Of course, what you are seeing may be some combination of intrinsic and extrinsic stain, which would further explain the variability in the appearance of your teeth. Besides a thorough professional cleaning to remove extrinsic stain, your options are the same as anyone else with intrinsic dental stain: 1-bleaching, or 2-porcelain laminate veneers. One or the other may be more appropriate, depending on the severity of the stain, the uniformity of the discoloration, the structural integrity of the teeth, and the position and shape of the teeth. Your dentist will be able to discuss the pros and cons of these two approaches.

A: Getting your teeth cleaned prior to bleaching makes good sense, for two reasons: You might decide that your teeth don't need bleaching after you remove all that coffee/tea/cigarette stain. Bleaching agents must come into intimate contact with tooth enamel in order for them to work. This cannot happen if your teeth are covered by a layer of plaque or similar accretion. Additionally, clean teeth are a virtue to which most people aspire. You don't want whitened dirt on your teeth-- you want whitened teeth! Also, due to the slight postoperative sensitivity following bleaching, a good cleaning may be more comfortably performed prior to this procedure.

A: The appearance of the teeth is due to a combination of their intrinsic coloration and that of any surface deposits. The intrinsic color of the teeth can be assumed to be what you see immediately after a good professional cleaning, assuming all surface deposits have been removed. If this color is not what you'd like it to be, it's unlikely that eliminating coffee, smoking, or anything else known to cause surface stains will yield sufficient improvement. In this case, benefit can be derived from some other cosmetic treatment, such as bleaching or porcelain laminate veneers.
On the other hand, if the color of your teeth after professional cleaning is satisfactory, you'll need to be a bit of a detective in determining just what is responsible for the surface stain. Common offenders include coffee, tea, and tobacco.

A: You say you have "smokers' teeth". If the stain you have on your teeth is the result of smoking, it is a surface stain (extrinsic) and can be removed in the course of a dental cleaning. This is NOT a cosmetic procedure, and should be covered by most dental insurance. If stain remains after your cleaning, either your dentist/hygienist has not done it properly, or the stain is "intrinsic", i.e., it is part of the coloration of the tooth itself, and cannot be "cleaned" off the surface. This stain may also involve any resin (white) fillings in the mouth; due to their porous nature, stain can penetrate these fillings. If composite resin restorations are stained, replacing them will effect a cosmetic improvement (the newer resins are more color stable, and will also benefit from your newly smoke-free mouth). Dental insurance companies will seldom deny benefits for a simple operative procedure such as a resin filling, regardless of whether it is being done for cosmetic reasons. It is true that most, if not all dental insurance plans will deny benefits for dental treatment done for solely cosmetic purposes, but oftentimes a functional or structural reason for the treatment can be furnished to the insurance company in a narrative by your dentist with the claim form. For instance, if it can be demonstrated on x-ray that a tooth is structurally weakened by fracture, decay, previous fillings, or root canal treatment, insurance companies may provide benefits for crowns or laminate veneers. Unfortunately, no insurance policies to my knowledge will allow benefits for in-office bleaching. There are do-it-yourself kits to be had, but are either ineffective (due to their relatively low concentration of active ingredient) or unsafe, due to the unsupervised nature of their implementation with potentially caustic chemicals. We could not in good conscience recommend unsupervised home bleaching to you, even if bleaching is an appropriate approach for your specific problem. A little gratuitous politicizing here: you say you "do not have the money to spend on something like this" and "My insurance does not cover cosmetic issues". If you truly believe that cosmetic enhancement is too capricious or frivolous to work into your personal budget, that is a legitimate conclusion that you are entitled to make. NEVER confuse an insurance company's determination of whether a service is REIMBURSIBLE with whether that service is necessary, appropriate, or advisable for you. The insurance company may be receiving your premium checks; your insurance may even be provided by your labor union dues. IT IS NOT YOUR ADVOCATE! Whatever moneys it doesn't pay out in benefits it gets to keep. Insurance companies deny many dental procedures in addition to cosmetics, based on the specifics of the policy fine print, for truly arbitrary reasons. Are you not going to have a needed root canal if insurance doesn't cover it? If you let them control the direction of your health care, they have won!

A: It stands to reason that practice makes perfect, and a "specialist" could render a service at a higher level of expertise than a generalist. Keep in mind, though, that the dental profession at large (organized dentistry, or American Dental Association) only recognizes nine specialties in dentistry, and "Cosmetic Dentistry" is not one of them. Anyone can call himself a specialist in anything, but he'd be technically wrong. (There have been movements afoot to create specialties in implant dentistry, cosmetic dentistry, general anesthesia in dentistry, even SUPERgeneral dentistry, akin to the emergence of the "family practice" specialty from the general practice of medicine. There are academies in these fields, which have set up their own criteria for membership.) I'd ask the respective dentists if they have photographs of their cosmetic work. We dentist love to photograph our work!

BTW, the nine dental specialties are:
Endodontics
Prosthodontics
Orthodontics
Pedodontics
Oral and Maxillofacial Surgery
Periodontics and Oral Medicine
Oral Pathology
Dental Public Health
Oral and Maxillofacial Radiology