Striving for that picture-perfect smile is a strong motivator behind one of the most popular cosmetic procedures, teeth whitening. However, while aesthetics are important, the health of the smile needs to come first. Those with periodontal disease need an organized and strategic approach to whitening that considers their medical condition.
“Sequence of Treatment” is an important principle in the practice of dentistry. In order to do elective cosmetic procedures, all health issues that are not related to the mouth need to be resolved. Whitening teeth when the periodontium is infected is not only ineffective, it is dangerous.
Phase 1: Identifying the Barrier – Periodontal Disease
Before the clinician is able to apply any whitening agent, the health of the gums, ligaments, and bone that support the teeth needs to be assessed. Periodontal disease is characterized by chronic inflammation due to a bacterial plaque biofilm that is below the gum line.
Why Periodontal Disease Stops Whitening Procedures
- Tissue Inflammation: Bleeding gums are a sign of periodontal disease. Whitening gels have a high concentration of hydrogen peroxide or carbamide peroxide. These whitening gels are very acidic and irritating to soft tissue. Inflamed gums will be even more sensitive. There is a high chance of chemical burns and pain if these gums are treated with whitening gels
+2 - Gingival Recession: Periodontal disease causes loss of gums and exposes tooth roots. The roots are not covered with the same hard surface as the crowns. Whitening may even cause great tooth pain because the whitening agents may cause sensitivity and irritate the dentinal tubules.
- Infection Control: Periodontal disease is a very active type of infection. It is never safe to do any type of cosmetic procedure when there is uncontrolled infection. The inflammation and infection completely disrupt the stability of any type of cosmetic work.
Phase 2: Stabilization Through Periodontal Therapy
The first thing that needs to be accomplished in the Sequencing of a Smile is to bring the mouth from disease to a state of health. Usually this is done with the non-surgical version of periodontal therapy, scaling and root planing (SRP).
Deep Cleaning and Debridement
In this phase of therapy, the Hygienist and/or dentist removes all of the subgingivally located plaque and tarter. This serves to reduce the bacterial load and allows the gums to improve. With time, the gum tissue will also improve and readhere to the tooth.
The Role of Adjunctive Antimicrobial Rinsing
During the stabilization stage, antimicrobial mouthwash is prescribed or recommended for the patients. This is an essential step in the process. A therapeutic rinse is able to accomplish a number of things. It can:
- Help keep the bacterial count in periodontal pockets low.
- Minimize bleeding and swelling that would otherwise be an obstruction to teeth whitening.
- Help slow or prevent the rapid re-colonization of pathogenic bacteria between in-office cleanings.
Once the “active” stage of the disease is arrested and timely evaluations of the periodontal condition show pink, healthy, and non-inflamed gingiva with no active bleeding and no increase in probing depth(s), the patient is moved to the “maintenance” phase. Only then may the concerns for cosmetic aspects be addressed.
Phase 3: The Healing Window and Color Stabilization
One of the greatest errors in the sequencing of dental therapy is the proximity of periodontal therapy to whitening. The gums need time after swelling and inflammation to settle. The shaping and molding of soft tissues can take months.
If whitening is done while the gums are still in an inflamed state, there may be significant whitening inequity and/or “black triangles” after the gums settle. To avoid the aforementioned issues, practitioners will typically wait at least four to six weeks after periodontal treatment before whitening is done.
Phase 4: Executing Safe Teeth Whitening
Teeth whitening can begin after a recipient has been given a clean bill of health. However, patients who have a history of periodontal disease require a specialized approach.
Selecting the Right Whitening Method
- In-Office Whitening: The dentist has the greatest amount of control with in-office whitening. A professional version of a “gingival barrier” (a light-cured resin) can be applied by the dentist to protect the sensitive tissue of the gums and to cover areas of recession. .
- Custom-Fit Trays: In-home whitening kits that include custom-fit trays, are a better option than whitening strips purchased at the drug store. Custom trays are made to the exact dimensions of the recipient’s gum line, thus preventing the whitening gel from entering the periodontal pockets or resting on the recessed surfaces of the teeth.
Managing Sensitivity
Patients with a history of periodontal disease whitening are more likely to experience “post-whitening sensitivity” than other patients. To help combat this, higher concentrations of desensitizing agents (potassium nitrate and fluoride) are required and should be applied both prior to and immediately following the whitening session.
Phase 5: Maintenance – Protecting the Investment
The combination of health and of aesthetics is the final stage of the approach. A smile that has been whitened is of little value if the gums that surround the teeth have poor health. The result of an investment whitens teeth while eliminating recurrence of periodontal disease.
The investment requires a strict regimen that includes removal of the biofilm by both brushing and cleaning between the teeth (flossing or use of interdental brushes) (mechanical cleaning).
- Mechanical Cleaning: Mechanical cleaning refers to the breaking apart of plaque biofilm through brushing and cleaning between teeth using floss or other interdental cleaning aids.
- Chemical Control: This refers to the control of plaque via the use of antimicrobial mouthwashes. These mouthwashes help keep plaque and other oral bacteria to levels where the immune system is able to combat the threat. It helps control the “staining” of teeth through plaque and helps keep the gums non-inflamed.
Conclusion: Health is the Ultimate Cosmetic
The “Sequencing of a Smile” outlines the hierarchy of importance of oral care. It is not possible to achieve a long lasting cosmetic treatment (e.g. tooth whitening) whilst leaving periodontal disease and other oral care needs untreated. It is important to first treat the gum disease, then allow the infection to heal, and only then is tooth whitening treatment appropriate.
The aim of the correct sequence is to achieve a treatment outcome that is not only a healthier and whiter smile, but one that will remain healthy and stable for years to come.