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To Bleach or not to Bleach after Periodontal Surgery.

From time to time, I am presented with questions from patients and colleagues regarding the safety of bleaching as it pertains to the health of the periodontium. I am also asked as to when home bleaching can begin following periodontal surgery. To answer these questions, one must review the bleaching process and have an understanding of periodontal wound healing.

The American Dental Association has approved several systems for home use bleaching agents which are meant to be dispensed by dentists. Most of these products utilize varying percentages of carbamide peroxide. Carbamide peroxide chemically breaks down to approximately 3% active hydrogen peroxide. The concentration can vary between products. Hydrogen peroxide forms chemically active free radicals which act as oxidizing agents that break down stain pigmentations. Extensive studies of ADA accepted bleaching agents have demonstrated both safety and efficacy

Numerous studies have evaluated the effect of varying concentrations of peroxides on periodontal health. The earliest work investigated peroxide use in oral hygiene products and their effects on gingival inflammation. Inflammatory changes are most commonly reported using the Gingival Index of Sillness and Loe. The index, commonly abbreviated as GI, scores inflammation on a scale of 0 to 3. A score of 0 represents healthy tissues. Most studies demonstrated mildly decreased levels of the inflammation when peroxides are included in oral hygiene regimens. These findings are consistent with studies evaluating the Keyes Technique, which incorporates the use of a mixture of salt, baking soda, and peroxide as the primary dentifrice. The majority of periodontal researchers have long recognized that these improvements were largely due to the affects of gingival masking. Masking occurs when the outer surface of gingiva appears healthy yet deeper layers continue to show histologic evidence of inflammation. It is helpful to use this as a basis of comparison when evaluating the reports below of improved GI scores in clinical trials with home bleaching agents.

Recent studies investigating the effects of bleaching derived peroxides cite reductions in gingival inflammation during the bleaching process. Most studies that I reviewed had baseline gingival index scores of approximately 1.00, indicative of mild inflammation. The improvements highlighted were demonstrated by reductions of 0.10 to 0.20 in the gingival index or modest gains at best. Isolated studies also reported a small incidence of mucosal irritation. Most of these reports cited ill-fitting and poorly constructed bleaching trays as the most notable source of gingival irritation during home bleaching trials. In all cases the conditions were regarded as transient and resolved upon the cessation of bleaching. Based upon my examination of these reports I would conclude that any improvement seen with respect to gingival inflammation is likely to have little or no effect on the pathogenesis and progression of gingivitis or periodontitis. Additionally it is apparent that, in the vast majority of cases, home bleaching is not harmful to the healthy periodontium when used in accordance with the manufacturers guidelines.

Evaluating the safety of home bleaching following a periodontal surgery requires an understanding of the chronology of wound healing processes that come into play after each particular type of surgery. My literature search did not find any studies that specifically addressed the question of how long of an interval should be allowed after surgery before commencing bleaching. However, conclusions can be inferred based on innumerable wound healing studies in the periodontal literature.

As a rule, periodontal surgery involving gingiva alone, heals far more quickly than surgery involving alveolar bone. Some examples of procedures in this category of surgery would be gingival augmentation grafts, frenectomy, fiberotomy, various soft tissue and brush biopsies, and gingivectomy. Most studies show complete epithelialization by 14 days following the surgery and complete keratinization at 28 days post operative. While these studies report normal surface architecture at 28 days, histologic studies demonstrate that connective tissue healing continues for a longer period of time. In my opinion, to be safe, the earliest I would advise using home bleaching products following gingival surgery would be two months after the procedure.

Periodontal surgeries involving alveolar bone take even longer to heal completely. Surgeries in this category include osseous surgery, guided tissue regeneration, bone grafts, crown lengthening, and implant surgery. Again, while surface tissue parameters may appear within normal limits at 28 days as in gingival surgeries, osseous and connective tissue changes continue far longer. A very well-fitting bleaching tray may hydrodynamically force the viscous bleaching agent through a weakly adherent periodontal sulcus to contact the deeper periodontal tissues. There are numerous studies that demonstrate cytotoxic properties of carbamide peroxide on gingival fibroblasts. Since this cell type is an important cell in the deposition of connective tissue, risking early exposure to peroxide after surgery involving alveolar bone is unwise. Therefore, in my view, home bleaching following periodontal surgeries of these types should be avoided for three months following the procedure.

Extreme caution and restraint in attempting home bleaching in patients with any evidence of oral pathologic lesions. These include some of the following conditions:, recurrent apthous stomatitis, herpes, desquamative gingival lesions, such as pemphigus vulgaris and cicatricial pemphigoid, and any other oral pathology lesion where the surface epithelium is eroded or otherwise altered.

In summary, using a bleaching agent following periodontal surgery can present risks which are easily avoidable by waiting and adequate amount of time until all healing is complete. Sound clinical judgment should be exercised when contemplating bleaching for any patient with an oral pathology lesion. Home bleaching is a wonderful esthetic service which more and more patients are desiring. It is safe and effective in periodontally healthy patients when used according to the manufacturer's instructions.

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