The influence of shade guide presentation sequence and psychosocial factors on patient tooth shade selection: A three-arm randomized controlled trial

Abstract

Purpose

To determine whether the presentation sequence of natural and bleached-shade options influences patient shade selection and to evaluate the association between the psychosocial impact of dental esthetics (PIDAQ) and final selected shade lightness.

Materials and Methods

In this three-arm randomized controlled trial, 210 participants seeking esthetic dental treatment were randomized to three shade-presentation protocols: Group A (natural → bleached), Group B (bleached → natural), or Group C (simultaneous full range with confirmation). Participants completed the psychosocial impact of dental esthetics questionnaire (PIDAQ) prior to shade selection. Initial “first-impression” and final shade selections were recorded using the VITA 3D-MASTER system with bleached tabs (0M1–5M3). Primary outcomes included switching between selections, lightness change (ΔL), and the association between PIDAQ and final selected lightness (final L). Secondary outcomes included bleached-shade selection, color-difference discrepancies (ΔE₀₀) versus objective baseline and clinician recommendation, and patient-reported rationale.

Results

Presentation protocol significantly affected switching frequency, ΔL* direction and magnitude, and bleached-shade selection (all p < 0.001). Switching was highest in Group A (31.4%) and lowest in Group C (1.4%). ΔL* showed protocol-dependent direction: a net shift toward lighter shades in Group A (+2.10) and toward darker shades in Group B (−0.93). Bleached-shade selection was most frequent in Group B (84.3%) and least frequent in Group A (31.4%). Higher PIDAQ scores were independently associated with lighter final selections (p < 0.001), with a significant Group × PIDAQ interaction (p = 0.006), indicating that the strength of this association varied by presentation protocol. Patient–clinician color discrepancies (ΔE₀₀) were smallest in Group A (7.68) and largest in Group B (16.24).

Conclusions

Shade guide presentation sequence is a modifiable determinant of patient esthetic preference and decision stability. Patients with a higher psychosocial impact related to dental appearance prefer lighter shades, but this preference is modulated by how options are presented. A structured protocol presenting the full shade range with a confirmation step minimizes decision volatility and may enhance patient–clinician alignment. Standardizing shade visualization by presenting the complete shade range consistently and incorporating a brief confirmation step can improve the predictability and transparency of patient-centered esthetic shade selection. Clinicians should be aware that early exposure to bleached options may unintentionally nudge patients toward lighter choices, particularly those with greater psychosocial concerns about their dental appearance.