Esthetic Dentistry Yields Bright Smiles — Under Clinical Guidance, Experts Say

Nov 6, 2019

A tray of orthodontic tools awaits a patient at Northwest Orthodontics in Fayetteville
Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIA

The quest for a perfect snow-white smile is being fulfilled for patients by a growing esthetic dental industry. But consumers who purchase esthetic oral care products online or in stories for at-home use should beware, expert say, of certain oral health risks. 

Dr. Kenton Ross has operated Ross Dental Clinic in downtown Fayetteville since 1997. He provides both restorative and esthetic treatment.

Dr. Kenton Ross shows one of his treatment rooms at Ross Dental Clinic in Fayetteville
Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIA

“Certainly patients want to look healthy so when we’re talking about cosmetic dentistry we are talking about tooth size, shape or position,” Ross says.

Beyond the realm of fillings and extractions, esthetic procedures, he says, are now routinely practiced by most dentists.

“Cosmetic dentistry can be as simple as replacing a chipped edge on a front tooth, or as complex as a smile makeover. With esthetic dentistry the goal is to address function, structure, biology and aesthetics.”

Ross offers patients an array of cosmetic choices.

"Like crowns, direct bonding, veneers, onlays and implants, and bleaching, whitening of the teeth.”

Tooth bleaching was first attempted in the 1950s, Ross says, using chemicals considered harmful. Today’s clinical whitening involves the carefully controlled application of concentrated hydrogen peroxide gel, activated with blue light.

“The blue light adds a little heat," he says, "the heat speeds up the reaction, so teeth whiten faster.”

Registered dental hygienist Kelsey Bowman at Ross Dental Clinic performs a cleaning to brighten a patient's teeth.
Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIA

Ross also makes custom mouth trays for patients to use for at-home bleaching, where patients apply a weaker peroxide gel. He also says store-bought bleaching kits are safe, but whitening in excess may have side-effects.

“It can increase sensitivity because it’s removing those things that have been insulating the teeth." 

For example tea, coffee, and wine stains, which build up on tooth surfaces. The roots of teeth can also be damaged from too much bleaching experts say.

“With over the counter whiteners, most are safe and you are not going to burn your gums," he says. "But with in-office and at-home bleaching, we want to be very careful how that’s applied because it can injure gum tissue.” 

Ross advises avoiding whitening tooth pastes which contain excess grit that can damage tooth enamel.

Tooth veneers, porcelain laminates cemented onto the front of teeth and bonded with a curing heat wand are another way to brighten smiles, Ross says.

Deteriorated teeth and exposed roots can especially benefit from crowns. Cast from materials like ceramic, porcelain or resin, crowns can restore normal shape, size, and function.

Dr. Kenton Ross uses a crown milling device inside his clinic to create custom-fitted crowns for patients.
Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIA

"With crowns we are holding that tooth together, because there are tremendous forces generated in the back of the mouth when we chew. So like much like rings on a barrel, the crown holds that tooth together and contains those forces."

Ross fabricates his own crowns using 3D imaging software and a countertop milling unit.

Dr. Jesse Gray DDS, who operates Northwest Orthodontics in Fayetteville, also uses 3D technology to straighten teeth.

“We have an inter-oral scanner that creates a  3-dimensional model of the teeth," Gray says. "With that model we can do different things. We can send it to companies to have clear aligners made, or print out a model where we have a process in our office to position [metal] braces on the model digitally. The braces are then placed on the teeth all at once. It's called indirect bonding."

Gray and colleague, Dr. Ryan O’Sullivan, along with a staff of fifteen, treat up to ninety patients per day, ages six to sixty-five, in a suite filled with reclining dental chairs.

“This is our clinical area, a large and fun room with music playing," he says. "Not much of the things we do are painful or uncomfortable so not a lot of stress or anxiety."

Dr. Jesse Gray DDS MS stands with colleague Dr. Ryan O'Sullivan DDS MS inside Northwest Orthodontic clinic in Fayetteville.Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIAEdit | Remove

Taking a seat inside his office, Gray says orthodontics has changed.

“In my sixteen years of doing this, it’s gone from everyone needing  [metal] braces to achieve a particular bite correction, to a majority of people being able to fix their smiles and bites with clear aligners, clear trays.”

Today’s braces are comprised of small metal brackets cemented onto individual teeth, when wired together progressively tighten and realign bites. For mildly crooked teeth, Gray will prescribe a series of custom-fit clear plastic aligners, which when worn daily gently move teeth into optimal placement.

A 3-D fabricated plastic mold of a patient's mouth is used to place metal bracing brackets.
Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIA

""Clear aligners showed up about 20 years ago, and initially were fairly limited in their application, for very minor things, but over the last 20 years they’ve evolved and become really, really powerful.”

Gray says in-office clear plastic aligners are most commonly used today by orthodontists to straighten teeth. And having straight teeth both contributes to self-esteem and and oral health, he says.

“If teeth are crowded it absolutely makes it more difficult for teeth to be cleaned. If teeth are crowded in such a way that they are  pushed out of gum tissue and bone, then you get gum damage and bone recession around the teeth, which can create sensitivity and even lead to tooth loss through life.” 

Many consumers are opting to purchase mail-order aligners from companies to use at home, rather than pay for clinical aligners.

“It’s definitely buyer beware," Gray says. "There are rarely if ever situations where changing the position of the teeth, whether its closing spaces or aligning crooked teeth, doesn’t affect the way teeth fit together, the bite. One of the most important things that I determine as an orthodontist is will accomplishing the change that the patient wants to affect, will that change their bite? And if so how am I going to compensate for that. There are lots of ways to do that, from reshaping teeth, to wearing elastics that hold the top and bottom teeth together. And other times we have to become more invasive with surgery to move the jaws to the correct position.”

An orthodontic technician at work inside Northwest Orthodontics 3D lab in Fayetteville where braces and teeth aligners are fabricated.Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIAEdit | Remove

Gray says he’s monitoring a patient who’s purchased and is using direct-to-consumer aligners -- to see if the process actually works.

“Another potential danger of a mail-order aligner would be if somebody had either a gum tissue or bone defect, a problem with the supporting tissues around the teeth.  Sometimes moving the teeth into a particular position can make that a lot worse. It could lead to tooth loss and lots of significant problems. So really the devil is in the details with this.”

Gray foresees direct-to-consumer teeth aligners becoming a hybrid industry, with dental professionals overseeing patient use.

Clinical orthodontic treatment costs for braces and aligners can range $2,000 to $10,000 dollars, with many procedures covered by dental insurance.  Direct-to-consumer teeth aligners cost between $1500 or more may also be covered, but only through insurance reimbursement or flexible spending accounts. 

Dr. John Rowe is former chair of the American Board of Cosmetic Dentistry and an Accredited Member of the American Academy of Cosmetic Dentistry. He maintains a cosmetic and functional restorative dental practice, Rowe & Rowe Smile Studio, in Jonesboro.

Credit Rowe & Rowe dental clinic

“Demand for clinical cosmetic procedures is growing amongst all demographics in the U.S,” Rowe says

In 2018 over $4 billion dollars in revenue was generated for esthetic dental services in the U.S., according to IBIS World Market Research.

A healthy smile can be a valuable asset, Rowe says.

“A study by two Princeton psychologists determined that people form a first impression of a stranger in one tenth of a second. Statistics show that people with a more attractive smile are generally more successful in interpersonal relationships including business and romantic settings.”

Rowe says esthetically produced smiles have become pervasive.

“Most times quality cosmetic dentistry will go unnoticed. People accept it as a beautiful natural smile.”

A beautiful smile has become an expectation among dental consumers, to which the dental industry is complying. For low-income patients, however, it can be a cost burden. Rowe says certain discount and free clinics are willing to do cosmetic procedures. And certain dental practices are willing to finance esthetic dental costs, seeing it as an investment in patients’ well-being.

Photos of satisfied patients are posted on Northwest Orthodontics "Smile Board."
Credit Jacqueline A Froelich / ARKANSAS PUBLIC MEDIA

“Whitening is an inexpensive way, cosmetic bonding, and changing the shape of the teeth can be relatively inexpensive, and those can provide, for a relatively small investment, some really striking results.”

Rowe says esthetic dentistry when done properly can be a life changing experience.

"I’ve seen that in my own patients, the increased self-confidence — it makes me feel good as a practitioner to be able to help people in that way.”

This story is produced by Arkansas Public Media, a statewide journalism collaboration among partner stations KUAR, KUAF, KASU and KTXK, and community partners AETN, and the Butler Center for Arkansas Studies. Arkansas Public Media’s series on oral health in Arkansas is funded through a grant from the Delta Dental of Arkansas Foundation, and with the support of its partner stations. You can learn more about Arkansas Public Media’s reporting at arkansaspublicmedia.org.