By Richard H. Nagelberg, DDS
What is there to write about tooth whitening that hasn't already been covered in previous articles and courses ad infinitum? Innumerable sources are available to provide information on intrinsic and extrinsic stains, peroxide whitening agents, managing patient expectations, Brannstrom's hydrodynamic theory of hypersensitivity, myriad desensitizing agents, in-office and take-home whitening products, documentation, the ADA's position on tooth whitening, etc. Is there any connection between whitening and the rest of the body?
Tooth whitening is clearly an elective service that must be undertaken appropriately within the context of all the patient's dental and medical needs. Diagnosis and management of disease and restorative needs are top priorities.
A few years ago, Dr. Charles Cobb analyzed insurance submissions for all dental services. Approximately 50% of adults between the ages of 30 and 70 have some degree of periodontitis; however, his evaluation revealed that periodontal therapy of all kinds accounts for only 5% to 6% of the total benefit codes submitted to insurance carriers. At the same time, insurance submissions for a variety of cosmetic services have risen significantly.
To even a casual observer, the significance of this disconnect is obvious. Realizing that the majority of periodontal disease cases are not being treated is stunning. How is it possible for this volume of disease to be ignored? How can any treatment need be addressed without observing diseased gums? How can a bloody prophy be completed without addressing the diseased gingiva, the cause of the bleeding, and all those red gauze pads? A simple interproximal restoration will likely involve the management of a bloody field. Providing tooth-whitening services, either in-office or take home, in the presence of periodontal disease is inappropriate at the very least.
Virtually all whitening agents utilize some form of peroxide, which creates an inhospitable environment for anaerobic bacteria, including the periodontal pathogens. To imply, however, that whitening agents can be used therapeutically for patients with periodontal disease is also inappropriate at the very least.
The need for diagnosis is fundamental to the ethical provision of health care of any kind. It is a simple, conscious decision to diagnose or not diagnose disease. It does not happen by accident. It becomes office policy under which all patients are treated the same, either the right way or the wrong way.
Unfortunately, failure to diagnose periodontal disease has implications for all involved, most importantly the patient. Just as excellent periodontal management has benefits beyond the oral cavity, failure to manage diseased gums has implications beyond the oral cavity as well, particularly for the vasculature. Maintaining or restoring a patient to ideal gingival health removes the risk posed by periodontal disease and the periodontal pathogens on vascular health. Ignoring periodontal disease perpetuates the risk.
When patients have their soft and hard tissue diseases addressed, tooth whitening can be undertaken with the knowledge and confidence that the patient is being properly managed. It is important to address the patient's esthetic desires. It is at least of the same importance to communicate that disease conditions have to be addressed prior to whitening or veneering, among others.
When undertaken in an ethical manner, tooth whitening is an excellent, conservative procedure that can make patients very happy with their new appearance as well as improving their satisfaction with the dental practice. It can boost self-esteem, enhance the likelihood of being hired or promoted in certain situations, and further careers in which appearance is important.
Research indicates that in-office and take-home whitening will produce the same results, the only difference being the speed of the results. In-office treatment is a viable option for patients who want their teeth whitened in one visit, rather than after some days or weeks of treatment. It is also a good option for patients who know they are less compliant in general. This may manifest as difficulty finishing a course of antibiotics as prescribed. In-office treatment may be indicated for these patients to avoid noncompliance with tray whitening.
The connection between tooth whitening and the rest of the body primarily involves the patient's satisfaction with their enhanced appearance, which is important to them.
Richard Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations, and he lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].
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